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Fig. 16.—The author’s method of palpating the liver. See page 192. 


fk BLUES 


(SPLANCHNIC NEURASTHENIA) 


CAUSES AND CURE 


BY 
ALBERT ABRAMS, A.M., M.D. (Heidelberg), F.R.M.S. 
CONSULTING PHYSICIAN, DENVER NATIONAL HOSPITAL FOR CONSUMP- 
TIVES, THE MOUNT ZION AND THE FRENCH HOSPITALS, SAN FRAN- 
CISCO ; PRESIDENT OF THE EMANUEL SISTERHOOD POLYCLINIC; 
FORMERLY PROFESSOR OF PATHOLOGY AND DIRECTOR OF 


THE MEDICAL CLINIC, COOPER MEDICAL, COLLEGE, 
SAN FRANCISCO 


ILLUSTRATED 


THIRD EDITION 
REVISED AND ENLARGED 


NEW YORK 
E. B. TREAT AND COMPANY 
241-243 WEST 23D STREET 


1908 


COPYRIGHT, 
BY 
E. B. TREAT AND COMPANY 
1904—1905—1908, 





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PREFACE TO THE THIRD EDITION. 


Tue additions to this edition are embraced by note 19, 
in the appendix and the chapter on intestinal auto-intoxi- 
cation. : 

The latter subject is more exhaustively discussed in my 
recent books “Man and his Poisons” and “ Diagnostic- 
Therapeutics.” Intestinal auto-intoxication as we now 
comprehend it, may be succinctly summarized as follows: 
During digestion, a number of poisons or enterotoxins are 
manufactured as a result of putrefaction of albuminoid 
food in the intestines. These enterotoxins attain the 
liver by way of the enterohepatic circulation where they 
are made innocuous. From the liver they pass into the 
general circulation and are excreted in the urine. If 
albuminoid putrefaction is excessive, or, if the liver and 
kidneys prove inadequate in either neutralizing or ex- 
creting the poisons, intoxication of the organism ensues. 
Intoxication is expressed by a motley group of ill-defined 
nervous symptoms which parade under the equivocal 
designation, neurasthenia. Now, this conception of in- 
testinal auto-intoxication is only partially correct. While 
the usual enterotoxins are bacterial products, there are 
also poisonous albumoses, ¢. ¢, intermediate products 
manufactured in the digestion of albuminous food-stuffs. 
It is well known, that when peptones and albumoses 
(normal products of digestion) are injected directly into 


169500 


PREFACE TO THE THIRD EDITION. 


the blood they are very poisonous, and even fatal. in their 
effects. Falloise * has recently had an excellent opportu- 
nity of studying this subject in a patient with a fistula 
communicating with the small intestine. He concludes 
that albuminoid-putrefaction is not the only process con- 
cerned in auto-intoxication and that an aqueous extract of 
the contents of the small intestine is infinitely more toxic 
than an extract made from the contents of the large in- 
testine. Hence, if we accept the prevailing opinion, that 
putrefaction of the albuminous molecule is limited in the 
norm to the large intestine, factors, other than putrefac- 
tion of the albuminous molecule must be concerned in in- 
testinal auto-intoxication. One must not forget that there 
is such a condition as “indigestion-toxemia” due either 
to an excessive production of poisons or from enfeeble- 
ment of the defenses. Thus there is an hepatic as well 
as a gastric and intestinal dyspepsia and the liver dare 
not be ignored even in the treatment of so Reba an 
affection as dyspepsia. 

In note 14, reference is made to massage of the liver. 
Sensitiveness of the liver is regarded by the author as 
the most trustworthy evidence of auto-intoxication and 
correct massage of the organ is a valuable aid in aug- 
menting the efficiency of the liver as an organ of defense. 
The most frequent point of tenderness is in the median 
line midway between the end of the sternum and the 
navel, and is demonstrable, by deep pressure at the end 
of forced inspiration during the time the body of the 
patient is inclined forward. 

Massage of the liver must be primarily executed by the 
physician, for unless it is done thoroughly no effects can 
be achieved. The results are almost immediate; the 


* Archiv, Internat. de Physiol. Vol. V. fasc. 2, p. 159, 1907, 


PREFACE TO THE THIRD EDITION, 


liver sensitiveness rapidly disappears and with its disap- 
pearance there is a corresponding improvement in the 
condition of well-being: 

Contrary to current opinion, I have found that in those 
suffering from self-poisoning, diarrhea, or at any rate, 
looseness of the bowels, prevails rather than constipation. 

Thus it is that after effectual massage of the liver, 
amelioration of the symptoms of auto-intoxication and 
splanchnic neurasthenia preceed part passu with a stool 
of firmer consistency without necessarily interfering with 
the regularity of the fecal evacuation. 

Very frequently massage of the liver alone without 
abdominal massage suffices in splanchnic neurasthenia 
and auto-intoxication, but in other instances, both must 
be judiciously combined. The author must again em- 
phasize the importance of correctly and thoroughly ex- 
ecuting massage of the liver, for otherwise no results can 
be expected from treatment and discredit will be unjustly 
cast’on the author’s conception of splanchnic neurasthenia. 
The author has found that massage of the liver properly 
executed will show the presence in the urine of indican 
although previously absent and if present before, it is in- 
creased after massage. 

Porter advocates the following simple test for indican 
which the author likewise finds trustworthy : 

Add in a test-tube equal quantities of urine and chem- — 
ically pure hydrochloric acid. To this mixture add 38 
drops of a 1 per cent. solution of potassium permanganate. 
If indican is present in the urine there will be formed a 
purplish cloud in the fluid in the test tube. Then adda 
few drops of chloroform, then one drop more of the 
potash solution and a few drops more of chloroform and 
shake vigorously. The deep blue color resulting is due 


PREFACE TO THE THIRD EDITION. 


to precipitation of indican by chloroform and the amount 
and intensity of the precipitated indican determine the 
extent of the putrefactive changes going on in the 
alimentary tracts. 

The subject of intestinal auto-intoxication, is intimately 
associated with splanchnic neurasthenia, more often, how- ~ 
ever, as an effect, rather than as a cause. Auto-intoxica- 
tion does exist as an independent affection and I venture 
to say, that the latter condition is frequently maintained 
by an insufficient splanchnic vasomotor mechanism. It 
is the disregard of the latter factor which nullifies our 
therapeutic efforts which are often conceded to be im- 
puissant in intestinal auto-intoxication. Disease typifies 
a reaction the resultant of two factors; a cause (the 
irritant) and the effect (the tissue changes). Some 
one has observed, that the ultimate trend of the phy- 
sician was to prove that even food was poisonous, and 
what has been suggested as a facetious prognostica- 
tion, appears to. have been endowed with reality, 
when one seriously contemplates the endeavors of die- 
etic revolutionists. Our dietetic sins can never be 
solved by faddists. Many dietetic vagaries are as con- 
sistent as the perfervid plea of the poet Shelley, who 
wanted us to become vegetarians and marry our sisters. 
The great danger with food lies in its excessive consump- 
tion and the evils frequently attributed to food may be 
minimized by habituation to changes in quantity rather 
than in quality. 

Dr. Abernethy made the discerning observation, “ There 
is no beast of burden in the world so overloaded as the 
human stomach.” 

With patients who are opposed to dietetic moderation 
one is constrained to employ methods which aim to 


PREFACE TO THE THIRD EDITION. 


combat alimentary insufficiency and to immunize the 
tissues against interminable dietetic insults. 

The latter object is best achieved by improving the 
splanchnic circulation. 

The author acknowledges with gratitude the cordial 
reception accorded to previous additions of his little book 
by the members of his profession and hopes, that the 
Same success may continue to be achieved in cases of neu- 
‘yasthenia which have proved resistant to the conven- 
tional methods of treatment. 

ALBERT ABRAMS. 

San Francisco, Cal., Feb. 1, 1908, 





PREFACE TO THE SECOND EDITION. 


Tus author, when he first introduced the affection, 
Splanchnic Neurasthenia, felt that he was treading on 
unknown territory and was apprehensive lest the pro- 
fession would regard his theory as another innovation 
which would soon be relegated to oblivion. To launch a 
new theory in medicine, with its surfeit of theories and 
theorists, is fraught with much risk to the offender, who 
must be prepared to await the fate accorded to nearly all 
innovations, viz.: condemnation, discussion and, possibly 
acceptance. My inauspicious prognostications, happily, 
were not fulfilled, and this finds expression in the early 
demand for a second edition. The author finds source 
for congratulation when so eminent an authority as Dr. 
J. H. Kellogg, in an address before the “International 
Electrical Congress” at St. Louis, stated that in his 
opinion the majority of neurasthenics suffered from con- 
gestion of the portal system and that the sinusoidal cur- 
rent to the abdomen is alone sufficient to produce great 
relief in a large class of neurasthenics. The author in 
his most recent work, “ Man and His Poisons,” published 
contemporaneously with this edition, seeks to elaborate 
the subject of self-poisoning, which is so closely identified 
with Splanchnic Neurasthenia. Notes 14 to 18 inclusive 
with illustrations have been added to the appendix in this 
edition. 

ALBERT ABRAMS. 





PREFACE. 


TueE object of this volume is to direct reference to a 
new and heretofore undescribed variety of nerve exhaus- 
tion, which I have designated as, Splanchnic Neuras- 
thenia. This special form of nerve weakness is charac- 
terized by paroxysms of depression of varying duration, 
and which are specified popularly as “* the blues.” The 
recognition of this special form of neurasthenia is of 
more than theoretic interest. One cannot say of it as 
did the mathematician, who, having demonstrated a new 
mathematical theory, thanked God that it could not be 
of the slightest utility to any living soul. A mere theory 
may be of interest to members of our profession, but the 
layman asks science for results. The recognition of 
splanchnic neurasthenia and the factors involved in its 
causation, imply our ability to cope with the evil and 
offer to the sufferers not only amelioration, but cure in 
many instances. My experience with neurasthenics has 
extended over a period of many years, and I know of 
no variety of neurasthenia which is more amenable to 
treatment than the splanchnic form. Various writers 
have hinted at an abdominal form of neurasthenia, but to 
my knowledge they have ignored the truesource of origin. 
A perusal of the subject matter of this volume will 
show that I have referred the origin of splanchnic neu- 


PREFAC®. 


rasthenia, in brief, to a congestion of the intra-abdom- 
inal veins. Man is distinguished from all other mam- 
mals by his erect posture. ‘If an intelligent extra- 
mundane ” says Campbell, ‘‘ were to see man for the 
first time in the horizontal posture, it would never occur 
to him that it is natural for him to be erect. There is 
something incongruous in an animal built on the longi- 
tudinal plan standing and progressing upon one end of 
its long axis.” The erect posture of man places him at 
a disadvantage in several directions, notably, however, 
by increasing the height of the blood column with a cor- 
responding increase of gravity on the circulation, thus 
causing the blood to gravitate into the intra-abdominal 
veins. Among the many resources of Nature to combat 
this tendency, the vigor of the abdominal muscles is par- 
amount. The tonicity of the muscles in question is 1m- 
paired by mal-hygienic clothing, occupation, disease, lack 
of exercise and a host of other conditions. Even a phy- 
siologie condition like pregnancy conduces to relaxation 
of the abdominal wall and pendulous belly, the so-called 
hdange-bauch of the Germans, and yet no one dreams of 
restoring the defective musculature after pregnancy by 
well directed exercises. The sports of the ancient 
Greeks were specially directed toward development. of 
the abdominal muscles. In the seulptural works of the 
old masters, the abdominal muscles are reproduced with 
as much accuracy as the other muscles of the body, and 
it is reasonable to assume, contrasting the art of the 
ancients with that of the modern sculptors, that the de- 
‘cadence of the abdominal muscles is a modern heritage ; 
and so are hemorrhoids, constipation, hernia, and a mul- 
titude of other evils that may be traced to enfeebled 
abdominal muscles. It is surprising how little can be 


PREFACE, 


achieved by feeble abdominal muscles, and how much 
_when the latter are developed by exercises. Individuals 
who would flinch when the slightest abdominal pressure 
was made, could after a few months’ use of the abdom- 
inal exerciser, throw heavy individuals seated on their 
abdomens, up and down, as serenely as though they were 
rubber balls. This exerciser permits essentially of trac- 
tions being made by the abdomen, although the exercises 
may be made in different directions. The abdominal 
exerciser is likewise available in developing other mus- 
cles of the body. In this connection, the experiments of 
Prof. W. G. Anderson, of Yale University, may be re- 
called with profit. The latter succeeded in practically 
weighing the result of a thought’s action. A student was 
placed on a “ muscle-bed,” poised on a balance so that 
the center of gravity of his body was exactly over its 
center. When the student was directed to solve mathe- 
matical problems, the increased weight of blood at. his 
head changed his center of gravitation and caused an 
immediate dip of the balance to that side. The student 
was further directed to imagine himself going through 
leg gymnastics. As the feats were mentally performed, 
one by one, the blood flamed to the lmbs in sufficient 
quantities to tip the balance, according to the movement 
thought of. His experiments warrant the conclusion, 
that the important thing in all exercises is the mental 
effort put forth: thus, walking is inadequate exercise for 
brain workers, as it is so purely automatic that it does 
not call the blood from congested brain centers, which 
continue solving intellectual problems. A run, a brisk 
walk, with a definite object necessitating the thought of 
speed, will send the blood to the legs and build them up. 
There are a large number of gastric and intestinal affec- 


a ae, 


PREFACE. 


tions with bizarre and protean symptoms, designated re- 
spectively as gastric and intestinal neuroses, but which 
in reality owe their genesis to a congestion of the intra- 
abdominal veins. Such affections are essentially forms 
of splanchnie neurasthenia and are specially amenable 
to the treatment suggested in this book. The affections 
in question often produce only local symptoms confined 
to the abdominal sympathetic, and may never extend be- 
yond the abdominal region to implicate the central nerv- 
ous system. The treatment I have advocated for the 
cure of splanchnic néurasthenia is based on purely phy- 
siological reasoning. My exposition of the subject of 
general neurasthenia I have purposely treated cursorily, 
as it was my intention to employ it as a medium only in 
introducing my special subject—splanchnie neuras- 


thenia. . 
ALBERT ABRAMS. 


CONTENTS. 


CHAPTER I. 


THE BLUES. 
PAGE 


The blues and its allied condition neurasthenia.—Heredity 
as a factor in the nervous constitution,—Personal effort as an 
element in resisting and overcoming an unstable nervous 
ee MEREEE RT Nc Me tpi tie ve efecaiels Sok tie AR A ceed AGEs CHIE Te» ees chO 


CHAPTER II. 


GENERAL IRRITANTS OF NEURASTHENIA, 


How irritants operate.—Overwork, worry, the abuse of al- 
cohol, bodily diseases, etc., as causes of neurasthenia.—The 
pathology of neurasthenia.—Brain changes in neurasthenia. 
Se AE UICRTIGUIASLLIOIIT ss 6 cs <isce'cs ols ¢ 000 4 ative ore's vloee's v's tee OO 


CHAPTER III. 


SPECIAL IRRITANTS OF NEURASTHENIA, 


The primary factor in neurasthenia.—Sexual neurasthenia. 
Uric acid neurasthenia.—Auto-toxemic neurasthenia.—Ab- 
dominal neurasthenia. — Dyspepsia and neurasthenia, — 
SOM eOUl Ae GNCIIAgs gs vcgss calcdccecsvcscecenscces (OO 


CHAPTER IV. 


THE GENERAL AND SPECIAL SYMPTOMS OF NEURASTHENIA., 


Motor disorders.—Sensory disturbances.—Eye signs.—Ear 
signs.—Brain signs.—Heart signs and the pulse.—Pulmo- 
nary anemia.—Stomach and intestinal signs.—Sexual signs. 
Forms of neurasthenia.—Diagnosis and prognosis of neu- 
LA a iclsicalnes cee teres sivcns pecs ches es cecesssseene. OO 


CONTENTS. 
CHAPTER V. 


THE GENERAL TREATMENT OF NEURASTHENIA. 
PAGE 
Objects of treatment.—Elimination of factors conducive to 
the disease.—Treatment of the disease.—Climate.—Treat- 
ment of the symptoms: insomnia, heart, stomach, intes- 
tinal and sexual symptoms.—Hypnotism as amode of cure. 81 


CHAPTER VI. 
SPLANCHNIC NEURASTHENIA.—THE BLUES. 


Why the term, ‘‘ the blues,” has been employed to specify 
this particular form of neurasthenia.—Data bearing on 
splanchnic neurasthenia.—Intra-abdominal pressure, pul- 
monary suction, vasomotor factor.—The abdominal sym- 
pathetic. — Factors contributing to splanchnic neuras- 
PHONID 5 voieec calc sere «hess Sonn «utes ae ere eet ey cer An oo! 


CHAPTER VII. 


THE SYMPTOMS OF SPLANCHNIC NEURASTHENIA., 


History of a splanchnic neurasthenic.—Analysis of the most 
prominent symptoms.—Relaxed abdominal walls, protru- 
sion of the abdomen.—Gas accumulation in the bowels.— 
Increased abdominal tenderness. —Enlargement of the 
liver.—Insufficient lung development....... soa:00-csi Se ee 


CHAPTER VIII. 


THE TREATMENT OF SPLANCHNIC NEURASTHENIA, 


The fundamental principles governing treatment. — The 
physical methods of treatment: abdominal massage, ab- 
dominal exercises, respiratory exercises, electricity, ab- 
dominal supporters and hydrotherapy.—Citation of cases 
of splanchnic neurasthenia. — Action of purgatives in 
splanchnic neurasthenia..........+ 55 «sas 6s sae eee eee 


CHAPTER IX. 
INTESTINAL AUTO-INTOXICATION. 


Factors determining auto-intoxication.—Symptoms.—Diagno- 
sis.—Treatment.—Hepatic insufficiency................. seo 


ae ae 


Pn Se See 


10. 
UM i 
12. 
13. 
14. 
15. 
16. 


Wy: 
18. 
19. 


APPENDIX. 


PAGE 
PULMONARY ANEMIA AND INSUFFICIENT DEVELOPMENT.... 189 


THE CARDIO-SPLANCHNIC PHENOMENON,.......e00see00+. 200 
BLooD PRESSURE....... Neate wae oe Nore dat eens eee LO 
THE STOMACH AND COLON IN RELATION TO THE HEART. 218 
PHYSICAL EXAMINATION OF THE LIVER......0cccsesevees Oe 
SS 00 Fig i 04 Gg 0 oe qe ae ge Se Sate va cls et ates 231 
CONDITION OF THE LUNGS ANTEDATING PULMONARY TU- 
BERCULOSIS AND BREATHING EXERCISES FOR DEVELOP- 


PEER UIGHIA UNO) i as Sk Vid OL Us Sts 40k RA ae ee ee ena tee 
PERISH BART. FE BLEX 2% ore erree cs ss te creer cE Re ae tre cede 237 
Tuer Luna REFLEX oF DILATATION......... Sd ae em 244 
He DUNG REFLES. OF CONTRACTION, ¢.. cc. e eens ws Ao eae € 
OEE PLENT 1 PRENS Scr css Us ets oF hawk ee Oe Ree RG k oe u's seo 
HIBRRDITY. «0056 0° GF id Ma ei bse nie RL a Sager See Ne wh eee 
THE SINUSOIDAL CURRENT...... eee as cha Pe ee ak aren OOO 
PASSAGE OF THE LIVER. .cccsss0se sees Ae LORE ae a enoo 
HuMAN METABOLISM.........- 5 Gey RAPER Ok ee ac FE 264 
CHEMICAL DEMONSTRATION OF THE ACTION OF THE SIN- 

PERRI CULLEN De cities cir eis balk ae he wreken Fee ce vrevie oe 266 
Trstinc INTRA-ABDOMINAL TENSION...........5. REPRO’ 
PERCUSSION OF THE STOMACH... 2... ccc ccs ereesccs at ee Ge 


THE VASOMOTOR TEST IN SPLANCHNIC NEURASTHENIA,... 275 


ee 





LIST OF ILLUSTRATIONS. 


PAGE 


Fig. 1. Points of election on the abdominal surface for ex- 
PCIE Mi ULOsDINSRAL Cr soe struc s ds v nace gees ne sc 136 
Fig. 2. Method for executing auto-massage...............6. 140 
Fig. 8. Apparatus for abdominal exercises. ..............4 146 
Fig. 4. Method of using the apparatus for abdominal exer- 
SC eB Bir OW eet a ae SPIO Sheena eR een Se 146 
Ree OWN DICUTAU SPACES. « or iek ae s'ss vistiat deen esse, 190 
Fig. 6. Pleural spaces on the lateral surface of the left lung. 190 
Fig. %. Patches on the front surface of chest................ 191 
Fig. 8. Patches on the posterior surface of chest........ ... 191 
Fig. 9. A, Clavicle. 1. Area of apex in normal breathing. 
2. Apical area in deep breathing. 38. Apical area 
after elicitation of lungreflex. B. Clavicle. Apical 
area after strapping lower chest..............000. 194 
Fig. 10. Extreme area of apical resonance on anterior surface 
OPEC QI bya Mearaccatn SaNI Sy ay + a wea oy ia a ee 196 
Fig. 11. Extreme area of apical resonance on the posterior sur- 
PEE CULE CHCSUR Ss owt i's s.5) eu oes ede ai eels ao Meee cs 196 
Fig. 12. Illustrating the cardio-splanchnic phenomenon...... 203 
Fig. 18. 1. Radioscopic appearance of the heart before in- 


sufflating the stomach. 2. Outline of the fundus 
of the stomach........ Se eae oe edie eta Sue ke 218 


Fig. 


Fig. 


Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 
Fig. 


Fig. 
Fig. 


Fig. 
Fig. 
Fig. 
Fig. 
Fig. 


14. 


15. 


27. 
28. 
29. 
30. 
dl. 


LIST OF ILLUSTRATIONS. 
PAGE 
i. Radioscopic appearance of the heart after insuf- 
flating the stomach. 2. Outline of the fundus of 
the stomach. oy oo. 0 oss civ ss bcos ate ie 219 
Patch of dulness in dislocation of the heart upward ; 


patient. in the erect. position... ¢. 21 vs! sae eee 220 
The Author’s method of palpating the liver. . Frontispiece 
Same case, patient leaning backward............... 221 
Fluoroscopic picture in dislocation of the heart.....- 222 
Method of percussing the lower liver border........ 220 
Arrangement of bottles for expiratory exercises.... 236 
Heart reflex in a boy aged eight years.............. 238 
Heart reflex in a boy aged fourteen years........... 239 
Illustration of heart reflex in cardiac dilatation...... 242 
Sphygmogram showing condition of pulse before in- 

haling’ ammonia) 2.062254 7.2% i¢ 2 fon oe 244 
Showing effects of ammonia during inhalation...... 245 
Mallet and pleximeter for eliciting the lung reflex of 

contraction 7... 2s a 4. ss bane eal er 248 
The lung reflexes of dilatation and contraction...... 249 
Respiratory Massage, .. 25 ss s% ss «vee wes eee ene 261 
Concussional Massages. ...5% .7. ss. cae one eee 262 
Gauging the motor power of the stomach........... 271 


Demonstrates the circulation of the blood and the 
effects of splanchnic congestion on the abdominal 
OPZANS Voi evs od sed ows Wee ENS 4 ee eu 273 


gia aeal) SHS. 


CHALTER I. 
THE BLUES. 


THE BLUES, AND ITS ALLIED CONDITION NEURASTHENIA.— 
HEREDITY AS A FACTOR IN THE NERVOUS CONSTITUTION. — 


PERSONAL EFFORT AS AN ELEMENT IN RESISTING AND OVER- : 


COMING AN UNSTABLE NERVOUS SYSTEM, 


Ruskin, in his ‘* Thoughts of Beauty,’’ is sponsor 
for the epigram, ‘‘ God has employed color in His 
creation as the unvarying accompaniment of all that is 
purest, most innocent and most precious.’’ [uskin, 
evidently never had a ‘‘fit’’ of the’blues. Why blue 
has been the color parodied to illustrate despondency 
is beyond my ken, for blue has been apostrophized by 
the painter, poet and litterateur as something expres- 
sive of heaven, the firmament, truth, constancy, and 
fidelity. The medical lexicographer pays no tribute 
to the blues, notwithstanding the fact, that it is se- 
curely incorporated in the vocabulary of every-day 
life. Iam with aforethought constrained to employ 
the term ‘‘blues’’ as it appeals with cogent signifi- 
cance to the sufferer, and for the additional reason that 
medical art has not truly interpreted its real pathology 
nor substituted for it, in itsnosology, a better or more 


technical name. The individual with the blues is 
13 


14 THE BLUES :—NEURASTHENIA. 


never an object of compassion. This luxury is denied 
him. Those nearest and dearest to him make him the 
butt of their ridicule and ascribe his varied and obscure 
symptoms to an undue indulgence of the imagination. 
Driven to despair, he seeks a physician, and the latter 
may or may not examine him; he may graciously 
deign to feel his pulse and examine his tongue, and then 
dismiss him with a prescription for a nerve tonic, and 
the erudite admonition, ‘‘not to become a crank.”’ 
Physicians are often astute philosophers in sickness, 
but such philosophy usually concerns the sickness of 
the other fellow. Sydenham, who loved his profession 
so well, was wont to observe that, ‘‘the medical 
art could not be learned so well and so surely as by 
use and experience; and that he who would pay the 
nicest and most accurate attention to the symptoms of 
distempers would succeed best in finding out the true 
means of cure.’’ And Plato contended that medicine 
was an art which considered the constitution of the 
patient and had principles of action and reason in each 
case. There is no symptom which has not a cause for 
its existence, and though the imagination prove opera- 
tive in exaggerating its significance, this merely proves 
that it is in itselfnot ina state ofhealth. ‘* No one,”’ 
avers Lavénge, ‘‘ can be ahypochondriac at pleasure.’ 
The unfortunate sufferer of the blues is acutely sus- 
ceptible to any imputation which discredits the honesty 
of his statements, and, apprehending no relief from his 
symptoms, soon falls into the ‘* slough of despond.”’ 
Such persons never feel ‘‘ just right ’’; their sleep is 
disturbed and the morning heralds the periodical de- 
pression and the unconsoling thought of unfitness for 
the routine work of the day. Memory becomes de- 
fective and loss of reason isapprehended. Then follow 


THE CAUSE AND CURE. 15 


sexual disturbances, indigestion, constipation, vague 
head sensations, palpitation of the heart, phobias and 
a train of obsctre and indefinite symptoms which baffle 
interpretation and add immeasurably to the suffering 
of the individual. The picture of the neurasthenic 
presents an insane revelry of the organs with the mind 
in the background, perceiving physiologic as pathologic 
functions. In the foreground stands the physician, a 
solemn witness of the scene, and whose face, the 
theatre of his soul, betrays the thought; how little 
power his art has given him to interpret objectively 
what is so acutely cognizant to the untortunate 
sufferer. The stomach of the patient may cause him 
untold agony, yet analyze his stomach contents and 
you will find that there is no anomaly of digestion ; 
examine his palpitating heart which, with every thump, 
increases his anxiety, and you listen to tones modified 
neither in intensity nor in cadence; and thus you 
proceed to examine organ after organ and there is 
nothing revealed; your examination is negative and 
your negative examination sustains your diagnosis ; 
you may call it what you will, neurasthenia or the 
blues. An attack of the blues is nought else but an 
acute neurasthenia or an aperiodic exacerbation of 
chronic neurasthenia. Neurasthenia having — been 
firmly established in medical technology, it will be 
under this name that the subject will be further dis- 
cussed. 

Dr. Beard, of New York, is the godfather of 
neurasthenia, having Hellenized its correlative nerve 
weakness. A medley of terms have been suggested to 
specify the varied symptoms and accompaniments of 
reduced nerve force, viz: hypochondriasis, nervous- 
ness, brain strain, nervous waste, nervous prostration, 


16 THE BLUES :—NEURASTHENIA. 


nervous exhaustion, nervous breakdown, spinal irrita- 
tion, etc., etc. The foregoing terms impose on us the 
assumption that we are here dealing with an essentially 
nervous disease, but further consideration of the subject 
may convince us, as we proceed, that in many examples 
of the affection, and I may add the great majority, the 
nervous symptoms are merely secondary. The cause 
may be resident elsewhere in the organism, the nervous 
system as the point of least resistance, merely reacting 
to repeated stimuli, like the rock which is pierced by 
the drop of water; not by its force, but by its frequency. 
The preceding view assumes, then, that two essential 
factors are necessary in the genesis of neurasthenia, 
viz: an enfeebled nervous system and an incentive, the 
erritant. 

The tale of every neurasthenic may be written in 
four chapters: 1. The sins of the. fathers. 2. The 
birth of a neurotic. 3. Struggle for existence on de- 
ficient nerve capital. 4. A bankrupt nervous system. 
Throughout the narrative, the continuity of human 
folly remains unsevered. ‘* Our lives,”’ says Darwin, 
‘Care but a bundle of consequences; our present is but 
the outcome of the past.”’ 

The patient who solicits the counsel of the physician 
submits himself as a problemn for analysis; his con- 
temporaneous symptoms proving only a link in the 
genetic chain. The physician, like the ontogenist and 
phylogenist respectively concerns himself not only with 
the evolution of the individual, but with his ancestral 
development. The question of heredity* as a factor in 
neurasthenia is an important one. Many modern 
neurologists contend that heredity is responsible for 
the majority of neurasthenics, and one prominent writer 


* Appendix, note 12. 


THE CAUSE AND CURE. ve 


recently demonstrated that in one hundred consecutive 
cases of neurasthenia, a neurotic history could be elic- 
ited in 70 per cent. of the cases. I feel confident in 
asserting that if one hundred consecutive patients came 
to me for the relief of so plebeian an ailment as corns, I 
would likewise find no difficulty in obtaining a history 
of morbid inheritance in a still larger percentage of 
cases. Wecomprehend, by neurotic heredity, a number 
of nervous diseases of direct hereditary character, trans- 
mitted from generation to generation. The hereditary 
taint may vary in degree from epilepsy and insanity to 
the less serious heritage, neurasthenia. The indica- 
tions of a neurotic heredity, known as stigmata, may 
be manifested by defects of moral sense, of memory, 
attention, will, or judgment. The stigmata of the 
degenerate may be physical, psychic or both. All 
writers who have made a psycho-anthropologic study 
of degenerates do not attach the same significance to 
physical stigmata as does Lombroso. The chief physi- 
cal stigmata are: cranial and facial deviation, recession 
of the lower jaw, large or small mouth and thick lips, 
abnormally shaped and misplaced ears, defective and 
misplaced teeth, and high palate. 

Criminal anthropologists find such deformities very 
common, although there are criminals who show no 
peculiarities, a type referred to by Lombroso, as, ‘‘ the 
criminal man.’’? Unless the physical stigma has at- 
tained such a degree of structural anomaly as to impair 
the normal function of a part, no great importance is 
attached to it. Some of the psychic stigmata are the 
following: 1. Precocity or retarded evolution of in- 
tellect. 2. Extreme changeableness and irritability. 
3. Exaggerated consciousness and a fanatical religious 


zeal or great moral depravity. 4. Intense egotism 
2 


18 THE BLUES :—NEURASTHENIA. 


with no regard for the feeling of others.’ 5. Extrava- 
gant and cranky motives and desires. 6. One-sided 
talents and disproportionate development of mental 
faculties. It was Hawthorne, I believe, who said, 
‘¢Once in every half century, at longest, a family 
should . . . forget all about its ancestors.”’ 

The hereditarian contends that ‘‘ the gods visit the 
sins of the fathers upon the children’’: ‘*That we 
are omnibuses in which all our ancestors ride ;’’ and, 
‘¢ that the life of each individual is, in some real sense, 
a continuation of the lives of his ancestors.’’? The 
pessimistic fatalism expressed in the preceding epi- 
grams seeks to eliminate the personal equation as a 
factor in disease, thus limiting the responsibility to 
heredity. We must not forget, however, that the 
autocratic reasoning of the hereditarian is by no means 
final, nor must we blindly submit to a ruling which 
would deprive the unfortunate neurotic of all hope. 

A recent writer, Prof. Putnam,! attempts to ex- 
plode the baneful argument of the hereditarian, and 
assures us that a just regard for the laws of hygiene 
will help to avert disease. He says that ‘‘ fortunately 
for the educational outlook, the evidence has begun to 
accumulate that a morbid inheritance is not the inev- 
itably crushing and baneful thing that it has been 
thought. We come into the world, each onea being of 
limited capacity, but, in other respects, free to become 
What circumstances make us, and responsible, to the ex- 
tent of our capacity, for our lot. We bring no ticket- 
of-leave which stamps us as drunkards or maniacs on 
probation, but we do bear, in the histories of* our an- 
cestors, a certificate that hints by what efforts and by 
what avoidances we can make ourselves reasonable 
successes in our respective lines. There is no original 


THE CAUSE AND CURE. 19 


sin, and not even, asit seems to me, original propensity, 
but only original capacity and original limitation, and 
even limitation is only another name for latent 
capacity.”’ 

Let us select consumption as a paradigm of an _her- 
editary disease, and learn to what degree personal effort 
is responsible in averting it. The modern physician 
assumes correctly that there is an inherited predis- 
position to pulmonary tuberculosis, and that the sus- 
ceptible individual, unlike the neurasthenic, betrays 
unmistakable objective stigmata of such predisposi- 
tion. If the physician, however, were dominated by 
the pessimistic fatalism of the hereditarian, he could 
extend no hope to the individual predisposed to con- 
sumption; but fortunately he has weaned himself 
from the irrational dogmas associated with this dire 
disease, and he can confidently say to the individual in 
question, ‘‘ Lead a regular and hygienic life and you 
have nothing to fear from the taint of heredity.”’ 

To prevent an unstable and mental nervous organi- 
zution, we must begin with the parents, and exercise 
always, from birth on, eternal vigilance, which is the 
only true passport to longevity and freedom from 
disease. It was Voltaire who said, ‘‘ If as much care 
were taken to perpetuate a race of fine men as is done 
to prevent the mixture of ignoble blood in horses and 
dogs, the genealogy of every one would be written on 
his face and displaved in his manners.’’? Homiculture 
or the physical culture of man corresponds to the 
means adopted in improving the breed of the lower 
animals. 

In these days, when sentiment and not reason 
dictates mating, it would prove fatuous to enlist the 
cooperation of the individual, and there is urgent need 


90 THE BLUES :—NEURASTHENIA. 


for legislative measures in this direction. Sanitary 
marriages need not detract from the sentiment which 
is associated with matrimony; on the contrary, they 
would confer on the matrimonial candidates a boon un- 
attainable by any other means, and the progeny of 
such marriages would receive health as a heritage, the 
most sublime gift which parents can bequeath to their 
children. 

Christian civilization need not emulate nor revive 
the laws of the Spartans, but from the latter many 
valuable lessons could be learned. The Spartans 
idolized what was beautiful and useful and sought by 
vigorous means to attain them. The sick were not 
allowed to marry, but the healthy were compelled to 
enter wedlock. Bachelors were publicly denounced 
after a certain age and banished from society. Mar- 
riage was not permitted in either sex until the age of 
maturity. The result of this Spartan system of mar- 
riage was to produce for five hundred years the strongest 
and bravest men and the most beautiful and healthy 
women that this world has ever known. 

The nervous and mental hygiene of the individual 
begins at birth and ends only with the extinction of 
life. It consists in the main of making the mind and 
body insusceptible to environment by imposing con- 
ditions which mean bodily discomfort and mental 
hardship. We must put ourselves in Nature’s place 
and work as Nature works, or, as Hufeland, puts it, 
‘¢The nearer and truer we are to Mother Earth, and 
the closer our intercourse with Nature, the closer we 
approach the source of Eternal youth and health; 
hence, it it only necessary to understand how nature 
intended that we should live in order to live long and 
comfortably ; art can do nothing to assist.”’ 


THE CAUSE AND CURE. at 
SUMMARY. 


1. The ‘‘blues’’ is a popular term emp oyed to 
express a multitude of ill-defined symptoms, mainly 
nervous, which have not, as yet, been included in the 
category of diseases. 

2. An attack of the blues is an attack of acute 
neurasthenia or an aperiodic aggravation of chronic 
nervousness. 

3. Nervousness, while expressive of an enfeebled 
nervous system, is an expression evoked by some irritant 
resident somewhere in the organism, other than in the 
nervous apparatus. 

4, Heredity may be responsible for the susceptible 
nervous system, and it devolves on the individual to 
obey the laws of hygiene and to avail himself ‘of 
momentary advantages, however minute, to withstand 
the effects of conditions which either weaken or im- 
prove the status of his vitality.’’ 

5. Heredity and environment may be effectually 
fought by personal effort. 





CHAPTER II. 


GENERAL IRRITANTS OF NEURASTHENTA, 





HOW IRRITANTS OPERATE. OVERWORK, WORRY, THE ABUSE 
OF ALCOHOL, BODILY DISEASES &C, AS CAUSES OF NEUR- 
ASTHENIA.—THE PATHOLOGY OF NEURASTHENIA.—BRAIN 
CHANGES IN NEURASTHENIA.—FATIGUE NEURASTHENIA. 


In the previous chapter, incidental mention was made 
of the causes of neurasthenia which, having their in- 
ception at birth, continue through life and are only ex- 
tinguished by death. ‘‘ As the twig is bent, the tree’s 
inclined.”? The mental and moral education of the 
child should be our primary concern. It is customary 
to regard neurasthenia as a disease of adult life, a con- 
tention which is as absurd as saying that adults only 
have a nervous system. The neurasthenic never seems 
to be rested; that ‘‘ tired feeling ”’ is always with him, 
and this susceptibility to fatigue constitutes the primary 
and fundamental symptom of the disease, and without 
it the disease cannot be said to exist. It is true that 
fatigue symptoms soon graduate into sensations of pains 
and aches, to recur again and again, until they are 
established as a permanent condition, dominated by a 
morbid mentality. In childhood, neurasthenia may 
be expressed wholly by the feeling of tire, and it is only 
rarely that the morbid physical sensations obtrude them- 


selves sufficiently in consciousness to make the mind a 
23 


O4 THE BLUES :—NEURASTHENIA. 


factor in the vicious circle. It has been customary 
recently to identify nerve force with electricity and if 
the analogy is not scientifically correct, it will at least 
subserve our purpose in enabling us to so manipulate 
our subject matter as to deal with something more 
tangible than nerve force. A recent writer, O’ Brien,? 
says, ‘‘I picture the nervous system and its mechanisms 
in living action before my mind; I see beside it the 
central telegraph system of New York or London, with 
its radii of lines and cables, telephonic and telegraphic ; 
its multiple switches, batteries, relays, transformers, 
condensers, resistances, shunts, duplex and automatic 
circuits: all this mechanism, lke the nervous system, 
transmitting force and translating intelligence from 
point to point by terminal instruments which move, 
talk, write, print, ight, inhibit, accelerate and regu- 
late and in one hundred ways doing what is done in 
the nervous system, and always by means of the same 
force, the only form of force capable of such vast and 
varied service. ’’ 

The voluntary, automatic and reflex movements of 
a child or adult, the employment of the senses and 
every thought means the expenditure of so much nerve 
force. When a muscle is fatigued by voluntary con- 
traction, it involves not only the muscle but the nervous 
system, and the latter to a larger degree than the 
former. It is erroneous to suppose that a healthy 
nervous system can be acquired by vigorous muscular 
exercise. The latter always means an expenditure of 
nerve force which may or may not be beyond the 
capacity of the individual. Many nervous wrecks are 
recruited from this fallaciousargument. Muscular ex- 
ercise is healthful to the extent of provoking pleasant 
recreation and relief{from mental work. Muscular ex- 


THE CAUSE AND CURE. 25 


ercise makes a predatory raid on nerve force which, 
being thus consumed, limits the mental powers of the 
individual. The nervous hygiene of childhood embraces 
the elimination of so many irritants that to enumerate 
them would be beyond the scope of this work. Suffice 
it to say, at this time, that tire in the child as well as 
the adult is the signal of warning. Tire is Nature’s 
call for rest. Heed Nature and there is no danger 
from any amount of work that we are desirous of do- 
ing. The other chief irritants of neurasthenia are: 
mental overwork associated with anxiety, worry or 
excitement, the abuse of alcohol, tobacco, coffee, tea, 
bodily disorders, physiologic factors and moral causes. 

Mentat Overworx.—Ruskin, has correctly observed, 
that, ‘‘ no great intellectual thing was ever done by 
great effort; a great thing can only be done bya great 
man, and he does it without effort. The body’s work 
and the head’s work are to be done quietly and com- 
paratively without effort. Neither limbs nor brain are 
ever to be strained to their utmost. That is not the 
way in which the greatest quantity of work is to be 
gotten out of them. They are never to be worked 
furiously, but with tranquillity and constancy. We 
are to follow the plough from sunrise to sunset, but not 
to pull in race boats at the twilight; we shall get no 
fruit out of that kind of work.’’? The Solomonic rule 
is not a bad one to follow, viz: eight hours for labor 
and occupation, eight hours for rest, refreshment and 
recreation and surcease of all labor, and eight hours for 
sleep. The nervous system must be made equal to its 
task. Nerve health depends on a moderate amount of 
_ work well diluted with healthful and cheerful recrea- 
tion. Gibson,? expressed a Utopian idea, when he said, 
*¢ Man is advancing to a stage when he shall no longer 


26 THE BLUES :—NEURASTHENIA. 


remain a stranger to his own life processes.’? It would 
be better for man were he conscious of his life processes 
in the sense of knowing his capacity for work and the 
need of rest when that is necessary. Such mental train- 
ing could be designated as physiologic introspection, and 
is the key-note of health. Holmes, in ‘‘ Over the Tea- 
cups ’’ speaks as follows of the curve of health: ‘It is 
a mistake to suppose that the normal state of health is 
represented by a straight horizontal line. Independ- 
ently of the well-known causes which raise or depress 
the standard of vitality, there seems to be—I think I 
may venture to say there is—a rhythmic undulation in 
the flow of the vital force. The dynamo which fur- 
nishes the working powers of consciousness and action 
has its annual, its monthly, its diurnal, even its mo- 
mentary ripples, in the current it furnishes. There 
are greater and lesser curves in the movement of every- 
day lifie—a series of ascending and descending move- 
ments, a periodicity depending upon the very nature 
of the force at work in the living organism. Thus we 
have our good seasons and our bad seasons, our good 
days and our bad days, life climbing and descending in 
long or short undulations, which I have called the curve 
of health.”’ 

The brain worker who works with discretion knows 
that the brain is capable of the greatest amount of 
work without fatigue during the early morning hours, 
for sleep has served to recuperate a fagged brain. 
The discretionate brain worker also knows that there 
is a daily ebb and flow of his nerve vigor. From the 
early morning hours the ebb of nerve force begins, at- 
taining its maximum discharge in the middle of the 
afternoon, a time when the nervously exhausted are 
the most weak. The evening meal temporarily stimu- 


THE CAUSE AND CURE. oT 


lates the brain functions, masking as it were the de- 
pressed state of the nervous system. Then follows 
sleep. The brain worker requires more sleep than the 
laborer. ‘There are certain individuals whose occupa- 
tions predispose them to neurasthenia. Thus it is, that 
merchants, professional men, teachers and others fur- 
nish large numbers of neurasthenics; their mental ap- 
plication is so profound and intense, that they exceed 
the limits of human endurance without a conscious 
knowledge of the fact. Then again, the brain worker 
is usually a neurasthenic, for, in this strenuous life of 
ours, mental achievement is only possible with a high- 
ly irritable nervous system. ‘* The power of original- 
ity in new lines of thought’? as Maudsley puts it, 
‘cand stepping aside from the beaten track of reflec- 
tion, is, of itself, a common indication of the insane 
neurosis. ’’ 

There are individuals who are incapable of appre- 
ciating the great amount of work they really do; they 
blunt their sense of tire by artificial stimulants and ex- 
citement. The latter class of individuals soon become 
drug habitués or end their lives in asylums as paretics. 
The predisposing cause of paresis so sententiously ex- 
pressed by Mickle applies with equal cogency to neur- 
asthenia: ‘‘ A life absorbed in ambitious projects with 
all its strongest mental efforts, its long sustained anx- 
ieties, deferred hopes, and straining expectation.’’ 
The individual who seeks to avoid neurasthenia by 
mental inactivity should hearken to the couplet of 
Cowper: 

** Absence of occupation is not rest, 
A mind quite vacant is a mind distressed.” 

The perpetuation of any living thing is dependent 
on the continuance of its healthy activity. 


98 THE BLUES :—NEURASTHENIA. 5 


Worry. An English writer of prominence asserts 
that the majority of people kill themselves by lives of 
indulgence of mind and body. Mental inactivity is 
injurious to physical health, and it is rare to find the 
idler among the list of centenarians. Healthy brain 
activity is essential to life and justifies the aphorism 
that ‘‘It is not work but worry that kills.’’ That en- 
viable man whom nothing worries is the kind, conside- 
rate and patient man whom we occasionally meet in 
this busy world. The ill-tempered, irritable and pes- 
simistic individual, with deranged digestion and bloated 
liver, is the man with an unbalanced nervous system, 
who has simply disregarded the natural law of waste 
and repair. Many acts of philanthrophy are forever 
lost in the capriciousness of a disordered liver or a de- 
fective digestive apparatus. Worry, grief, passion and 
fretting are powerful nervous shocks. ‘There is no 
sensation,’’ says Tuke, ‘‘ whether general or special, 
excited by agents acting on the body from without, 
which cannot also be excited from within by emotion- 
al states affecting the sensory gangla, such sensation 
being referred by the mind to the point at which the 
nerve terminates in the body.’’ The emotional states 
arrest the function of digestion and impair the bodily 
functions. Self-control is a powerful palladium against 
nervous prostration. It is exceptional to find a neu- 
rasthenic in individuals who have acquired a knowledge 
of self government. ‘‘ Every one can master a grief 
but he that has it,’’ but we are all competent to con- 
struct for ourselves a philosophy of complacency. Such 
philosophy need not resolve itself into indolence and 
apathy, nor need it assume the aspects of stoicism. 
When misfortune or disaster overtakes the Turk he at- 
tributes it to the will of God, or more often to fate 


THE CAUSE AND CURE. 99 


(Kismet), and he piously ejaculates: ‘It is fate’? (As- 
met dir) or ** God will provide’”’ (Allahkerim). 'The cul- 
tivation of some belief which inculates the doctrines of 
contentment should be encouraged. It may be a diffi- 
cult matter to control the emotions, but mastery can 
_ be attained by training. I know many neurasthenics 
who suffer relapses whenever exposed to some intense 
emotion. When self control is difficult, individuals 
‘must avoid conditions which introduce them to such 
influences. They must avoid going to funerals, read- 
ing death notices and newspapers with their daily 
menu of sensationalism. They should cultivate the 
companionship of people who may dream of unhappi- 
ness but wake up laughing. The worries of some 
people are often so ridiculous that they must be re- © 
garded as the emanations of a diseased mind. I knew 
one woman, who, after a rest cure for neurasthenia, 
suffered only one inconvenience, and that was, that 
she had heard that recovery from a ‘‘ rest cure’? only 
lasted five years, and at the end of that time she feared 
she would suffer a relapse. My patient was very much 
like the woman whose physician asked after her health 
replied dolefully: ‘‘I feel very well; but I always 
feel bad when I feel well, because I know I am going 
to feel worse afterwards. ”’ 


THE ABUSE OF ALCOHOL, COFFEE, TEA, AND TOBACCO. 


AxconoL, is one of the greatest scourges of the nerv- 
ous system. Consumed even in the smallest amounts 
by persons of a nervous temperament it will induce or- 
ganic changes in the nerve tissues like those of old age. 
The habitual use of alcohol stands foremost, after hered- 
ity, as a single independent cause of insanity. The 


30 THE BLUES :—NEURASTHENIA. 


psychic degeneration of alcoholism is characteristic, 
and consists of gradually weakening memory and will, 
slowness of perception and judgment, loss of the moral 
and esthetic sense, with paroxysms of depression, anger 
and irritability. There is no organ of the body which 
is not implicated in chronic alcoholism, but it is as a 
nerve intoxicant that its most pernicious effects are 
manifest. The nervously inclined first become addicted 
to alcohol in some form believing that it is a stimulant. 
This is not a fact, for its chief action is depressant and 
under its influence the actual amount of work that is 
capable of achievement is less than when it is not taken. 
The stimulating effects of alcohol are more apparent 
than real. By anesthetizing sensation, a temporary re- 
lease only 1s secured from the morbid sensations ex- 
perienced by the neurasthenie. 

Morphin and a host of other remedies have a like 
effect, and it is this fictitious sensation of well-being 
that is responsible for the prevalence of drug addiction 
among neurasthenics. There are many neurasthenics 
whose symptoms may be directly traced to the alcohol 
habit. Such individuals suffer from gastric and 
nutritional disturbances, mental symptoms and para- 
lysis. 

The neurasthenic must be especially warned against 
the so-called ‘‘nerve foods’’ and other preparations 
advertised under fascinating names by unscrupulous 
manufacturers, for many of them contain powerful 
sedatives, which are merely palliative in their action and 
ultimately conduce to some pernicious drug habit. 

Correr, TEA and Cocoa. Caffeine, the active princi- 
ple of coffee, theine, of tea and the alkaloid of cocoa are 
chemically identical and have the same vicious effects 
when used inordinately. Many nervous affections are 


THE CAUSE AND CURE. ol 


wholly attributable to their use, in fact, they may dup- 
licate all the symptoms of neurasthenia. Nervous indi- 
viduals display a definite idiosyncracy toward these sub- 
stances, hence they should never be employed in such 
persons. | 

Bopvity Disorpers. Syphilis is a paradigm of this 
type of irritants. Here many factors conspire to 
make the subject a likely victim of neurasthenia. 
First, there is the mental factor, for there are 
many persons who once having contracted the disease 
interpret every bodily derangement as a manifestation 
of syphilis. Then there is the reduced state of the 
body induced by injudicious medication, or by the 
poison of the disease itself, which makes the subject 
susceptible. Nutritional disturbances provoked by 
syphilis often make the nervous system the object of 
least resistance. Syphilophobia, or the morbid dread 
of having contracted syphilis produces intense mental 
suffering in some individuals and it is also the case 
when other venereal diseases have, or are supposed to 
have been acquired. The anxiety of mind conquers 
the entire being. Sleep, digestion and nutrition are 
in consequence impaired, and the unending terror may 
last a lifetime unless controlled by the physician, who 
is often able by the modern aids of science, to make 
innocuous the indiscretions arising from venereal disease. 
Often the sexual madness has no real foundation; a 
harmless skin eruption, lax, or too lightly drawn 
testicles, innocent pimples and the like are apt to be 
construed as manifestations of venereal disease. 

InriuENzA. This affection is likely to be followed by 
neurasthenia which is sometimes severe, prolonged and 
obstinate. Other infectious diseases, like malaria and 
typhoid fever as well as other debilitating diseases are 


32 THE BLUES :—NEURASTHENIA. 


not infrequently followed by neurasthenia, and, indeed, 
the convalescence of such diseases is made up almost 
wholly of neurasthenic symptoms. 

Rattway Insvurtes. <A nervous condition may follow 
railway and other injuries, especially when associated 
with fright. The neurasthenia following such acci- 
dents isknown as traumatic neurasthenia, or ‘‘ railway 
spine,’’ and differs in no wise from neurasthenia de- 
pendent on other causes. 

Puystotoaicat Facrors. Puberty in both sexes, and 
the puerperal state and change of life in women, as 
well as the tissue changes peculiar to old age (senzlity), 
are periods in life when the nervous system is subject 
to excessive strain which increases its vulnerability. 
Puberty occurs between the thirteenth and twentieth 
years, a period of life in which remarkable physical 
and mental changes occur. The evolution of the 
sexual characters and development of reproduction, 
give rise to new sensations and strong emotions. The 
mind, especially of the boy, becomes charged with 
emotional, sentimental, amatory and fantastic imagin- 
ings and vicious habits are formed. In the puerperal 
state pregnancy diminishes the vitality of woman, de- 
bilitating and weakening her entire system, thus mak- 
ing her a prey to the many disorders consequent on 
nervous breakdown. 

The change of life (menopause), in women between 
the ages of forty and fifty vears, is another epoch 
fraught with mischief to the nervous system, and it is 
rare “to find in this period of involution, a woman free 
from nervous manifestations. 

The disequilibration associated with the cessation of 
ovulation and menstruation is a menace to mental 
integrity. 


THE CAUSE AND CURE. 23 

During the senile period of life, tissue involution is 
likely to be attended by numerous mental disorders. 
A conspicuous sign is loss of memory for recent events 
and the individual’s interest becomes centered in his 
physical comforts and needs. 

Morat Causes. It is an axiom, that every time a 
muscular movement is made, less resistance is made by 
the nerve center in control of that special motion, and so 
it is with the moral education of the child, the oftener 
the latter is permitted to perpetuate a wrong, the 
easier will its repetition become. Discipline of the 
child begins at home and attention to their morals is 
more important than books. —‘‘ A. man,’’ said Johnson, 
‘is in general better pleased when he has a good din- 
ner upon his table, than when his wife speaks Greek,”’ 
and a parent would be better pleased if his boy could 
be taught to escape the dominion of habit by self con- 
trol than if he knew all the Euclideanaxioms. Unfor- 
tunately the boy does not know until later in life that 
self-denial is of more value than indulgence. ‘‘ Those 
who would be young when they are old should be 
old when they are young. Old age in youth should 
mean parental control. 


BRAIN CHANGES IN NEURASTHENIA, 


Physiologic experiments demonstrate that in fatigue 
of the nervous system, the nerve cells, which in health 
are plump, become shrunken and become restored to 
their original shape and size only after prolonged rest. 
Brain cells have been compared by a recent writer to 
small baloons ready for an ascent. When seen under 
the microscope they are round and full and give evi- 
dence of being distended. The cells of the tired brain, 


3 


34 THE BLUES:—NEURASTHENIA. 


on the other hand, are seen to be shrunken, as an air 
ball or toy baloon, from which most of the air or gas 
has escaped. 

When our brains begin to work after a refreshing 
rest or sleep they are, continues the same writer, full of 
nerve fluid, which the absorbents of the body and brain 
have stored up there like bees fill theircomb. So soon 
as work begins, this vital force is sapped to meet the 
demands upon the brain, and the process that goes on 
during the whole time it is working may be described 
in the following way : 

Imagine that these cells are small goblets filled with 
liquid, and that they have a tiny stem, through which 
runs a tube or opening; the liquid in the goblet is 
drained by the demands of mind and body, and slowly 
trickles through the opening, drop by drop, until either 
the work ceases or the goblet is exhausted. 

This latter condition is not often reached, for the 
simple reason that the owner of the brain is very much 
more likely to collapse. When the cell has yielded 
half its vital fluid you begin to experience a feeling of 
fatigue, and if you goon drawing the contents of the 
cells you are doing yourself injury in proportionate de- 
gree, and nature will make you pay for it in some way 
or other. 

But all the cells are not involved in any kind of 
mental work, which means that one part of the brain 
may be very actively at work while the other is rest- 
ing and storing up nerve fluid. Thus it is that a man 
suffering from brain fag may leave his books and go 
golfing or cycling and feel that he is really resting, 
other cells are being called upon for work now, while 
the tired ones, those required for mental activity are 
enjoying repose. 


THE CAUSE AND CURE. 35 


But it follows that the part of the brain which is 
called into activity for bodily exercise is now getting 
tired, while the other part of the brain is still at work 
to some extent, and so the whole of our brain cells be- 
come fatigued, and total rest, in the shapeof sleep, is 
absolutely essential. 

The ‘* neuron theory ’’ of Hodge,* is of special interest 
in determining the pathology of neurasthenia. Hodge 
studied the nerve cells of swallows, pigeons and bees 
before and after fatigue and in all cases he observed 
noteworthy changes. After rest, the cells were large 
and plump, well defined and the nucleieasily demons- 
trated. After a day’s flight, the cells became small, 
the nuclei indistinct, the protoplasm granular and 
shrunken and the cell processes striated. Dercum 
claims, that in chronic cases of neurasthenia, the blood 
contains toxic substances derived from the excessive 
waste of nerve tissue ; and Mosso, who injected the 
blood of a fatigued animal into one at rest, obtained in 
the latter the characteristic signs of fatigue. The con- 
clusion that may be formulated as the result of the 
preceding observations is practically as follows: 

Fatigue NreurastHenta. Thereis a newrasthenia de- 
pendent on overwork or over-functioning, a form cor- 
rectly specified by Savill,® as ‘‘ fatigue-neurasthenia ”’ 
which is dependent on exhaustion of the nerve cells. 
The latter which may be aptly compared to electric 
cells furnish a definite amount of electricity, but after 
continuous use without intermission, they exhaust 
themselves, and their output of electricity, an expres- 
sion of their function, becomes diminished and the 
mechanism of the organs can no longer be put in mo- 
tion, or, if so, with great difficulty. Rest will restore 
the storage capacity of the nerve cells as it will the 


36 THE BLUES :—NEURASTHENIA. 


electric cells. There is the law of Edinger which is 
quite apposite in relation to neurasthenia, viz: in- 
creased function, if regularly and gradually increased 
leads first of all to increas growth; if carried to excess 
however, or is irregular and spasmodic, it leads to 
waste and degeneration of the tissues concerned. 
Every function of the body is controlled and operated 
by the nervous system. The latter which doniinates 
the functions of the mind likewise controls the action 
of the muscles. We haven’t two nervous systems nor 
two brains and it is this mistaken conception of the 
functions of the nervous system which has made con- 
firmed neurasthenics out of individuals who have ex- 
pended too much nerve force in excessive muscular 
development under the supposition that they were de- 
veloping their minds. If the theory of muscularity 
were correct, intellectual giants would be recruited . 
from dray horses and pugilists. 


"a 


THE CAUSE AND CURE. 37 
SUMMARY. 


1. The chief symptom of neurasthenia is tire. 
Without the latter sign, the disease cannot be said to 
exist. 

2. While neurasthenia occurs most frequently be- 
tween the ages of twenty and fifty, it may occur during’ 
other periods of life. Children are by no means exempt 
and, if the affection in the child is unrecognized, it is 
because the nervous system of the child reacts differ- 


‘ently to the exciting causes than does the same system 


in the adult, and for the additional reason, that the 
mind in the child is eliminated from participation in 
the physical symptoms. 

3. Nerve force, has been compared to electricity, 
but this comparison does not improve our conception of 
the nature of nerve force, which like electricity is very 
obscure. The comparison will aid the neurologist in 
framing a positive knowledge concerning the action 
and laws that govern nerve force, which in relation to 
electricity are precise and extensive. 

4. Muscularity is not essential to intellectual deve- 
lopment, on the contrary physical overwork drains our 
capital of nerve force and disturbs the equilibrium of 
mental and physical health. The ‘‘ mens sana in cor- 
pore sano’’ can only be attained by a judicious exercise 
of both mind and body. 

5. Nerve health is a condition subject to the discre- 
tion of the individual: it is the resultant of the income 
and expenditure of nerve force. 

6. Stimulants, like drugs used for the relief of nerv- 
ousness, have been invented for both the patient and 
physician. They relieve the former of obeying the 
laws of hygiene and the latter of inculcating them. 


38 THE BLUES :—NEURASTHENIA. 


They assist in the early death of foolish neurasthenics 
so that their fellow sufferers may learn the correct 
path to health. 

7. ‘¢They who would be young when they are old, 
must be old when they are young.’? Everything 
which promotes the general health will promote re- 
covery from neurasthenia, for anything which will in- 
fluence health will have a corresponding effect on 
health. 

8. That ‘‘ An idle brain is the devil’s workshop,”’ 
is never better illustrated than in an insane hospital.” 

9. In studying the relation which exists between 
venereal and nervous diseases, we note the will of 
omniscient Providence dedicating to virtue, vigorous 
manhood and a noble life. When a staid and respected 
member of society, developes in later years a post- 
venereal disease, the picture he presents, is that of re- 
spectability painted on a back-ground of vice. 

10. Neurasthenia has no definite pathology and all 
hypotheses which hint in that direction have not ex- 
ceeded the realms of theory. We recognize the 
disease as we do the physical forces by their effects, 
viz: an acute or chronic functional nervous trouble 
manifested by nervous weakness and irritability, in 
which the patient is easily exhausted and is acutely 
responsive to trivial irritations. 

11. Self-culture embraces a training of the physical, 
moral and intellectual parts of man. All must be 
equally and judiciously trained. An exclusive train- 
ing of the physical part will develop an athlete; of 
the moral, an enthusiast ; of the intellectual, a crank. 


CHAPTER III. 
SPECIAL IRRITANTS OF NEURASTHENIA. 


THE PRIMARY FACTOR IN NEURASTHENIA.—SEXUAL NEUR- 
ASTHENIA.—CONGESTIVE NEURASTHENIA.—URIC ACID 
NEURASTHENIA.——AUTO-TOXEMIC NEURASTHENIA.—AB- 
DOMINAL NEURASTHENIA.—-DYSPEPSIA AND NEURAS- 
THENIA.—SPLANCHNIC NEURASTHENIA, 


In the preceding chapter, the cause of neurasthenia 
was attributed in brief to overstrain of the nervous 
system provoked by the various mental, moral and 
physical causes, the result, as Beard puts it of over- 
civilization. Very soon investigators sought to ex- 
plain how this irritability and weakness of the nerve 
cells was brought about. Medical writers are being 
rapidly weaned from the doctrine that an hereditarily 
degenerate nervous system is the primary factor in 
neurasthenia. The assumption of such an hypothesis 
would mean the relegation of personal responsibility to 
heredity and would grant immunity to the transgressor. 
The fact is, that a number of neurasthenics owe their 
infirmity to indiscretions, and a still larger class to 
morbid organic functions, which, if corrected, would 
cure their disease. 

Charcot claimed that the working-classes were not 


exempt from neurasthenia; on the contrary, physical 
39 


40 THE BLUES :—NEURASTHENIA. 


fatigue, poverty and the constant anxiety to make 
both ends méet were as potent in inducing neuras- 
thenia as the brain work of professional or business 
men. 

Physicians now recognize that certain predisposing 
influences exist to induce neurasthenia, even though 
an inherent weakness of the nervous system can be ex- 
cluded. 

As a result of this recognition, reference is now 
made to special forms of neurasthenia which will en- 
gage our attention. 

Many affections which have hitherto been recognized 
as diseases by themselves are either symptomatic of 
neurasthenia or induce the latter affection by their 
persistency. 

SexuaL Nevurasruenta. In their monograph on 
Sexual Neurasthenia,®é Beard and Rockwell, refer 
to the various maladies of the male sexual appara- 
tus, viz; impotence, spermatorrhoea, prostatorrhea, 
irritable prostate, etc., as mere manifestations of 
neurasthenia. The trend of modern opinion is not 
only to regard sexual ailments as manifestations of 
neurasthenia, but as the cause of the affection. Again, 
the state which sexual disorders induce is not neces- 
sarily a neurasthenic one. Witness as an instance the 
masturbator. His condition is one of mental de- 
pression with disinclination to work and study. He 
is nervous and irritable: numb feelings are felt in the 
hands and feet, etc. His physiognomy is character- 
istic and by no means tallies with that of neurasthenia, 
viz: pale complexion, furtive eye, dilated pupil, restless 
and depressed appearance, moist and flabby palms, 
etc. In women, masturbation is a frequent cause of 
hysteroepilepsy. Freud? avers that neurasthenia can 


THE CAUSE AND CURE. 41 


always be traced to excessive masturbation, unnatural 
sexual intercourse, unsatisfied impulses, abstinency with 
inflamed desires, interrupted coitus, etc., and he urges 
the physician to assume an abnormal sexual life as his 
guiding star in the causation of neurasthenia. 

Hottinger ® contends that many functional de- 
rangements of the genito-urinary system, which have 
been referred to as symptoms of neurasthenia, have 
as their basis some form of prostatitis, and that the so- 
called neurasthenia disappears when the prostatitis 
is cured. Fuller® refers neurasthenia to a seminal vesi- 
culitis; Ravogli to a chronic urethritis and syphilis; 
and Eastman? to impaired sexual gratification, lacera- 
tion of the perineum, etc. in women. The foregoing 
writers are unquestionably extreme in their views, but 
their observations convey a modicum of truth if for 
no other reason than to emphasize thata local source 
of irritation may be responsible if not for neurasthenia, 
at least for neurasthenic symptoms. 

ConcestIvE NevrasrHEniA. Whittle, of London, in 
1889, wrote an interesting brochure on this special 
form of neurasthenia, but it seems to have escaped the 
serious consideration of the medical profession. Ihave 
repeatedly been able to confirm the observations of 
Whittle. He describes a form of nerve depression re- 
sulting from brain congestion and illustrates the re- 
markable efficacy of bloodletting, either by leeches or 
venesection, in itstreatment. The particular patients, 
who are thus benefited, look to the uninitiated eye, the 
picture of health, but are really miserable victims to 
whom actual pain or some evident disease would prove 
an agreeable distraction. Their faces are flushed, eyes 
watery and there is a lightness in the head with occa- 
sional aching of a dull, heavy character about the fore- 


49 THE BLUES :—NEURASTHENIA. 


head. The majority of cases occur between the ages of 
thirty and forty, very few under twenty-five or over 
fifty. Thisincludes the most active and wearing period 
of life. Ifa man can stand the strain of this period, he 
will be proof against anything he may encounter 
afterward. Congestive neurasthenia occurs more fre- 
quently in males than females and the most constant 
factor in-its production is continuous brain strain. 

During sleep, such as it is, the body rests but not 
the brain. As a result the brain becomes unduly 
charged with blood, leading to congestion, which noth- 
ing seems to relieve so quickly and marvelously as 
blood-letting. Leeching is one of the good remedies 
out of fashion, and while formerly it was the custom 
to bleed too much, itis unfortunate that now we do not 
bleed enough. I remember one congestive neurasthenic 
who, by actual calculation, had consulted twenty-three 
different physicians, among whom were some of the 
leading nerve specialists of Europe. In addition he 
had made a number of sea voyages and visited many 
celebrated spas but with absolutely no relief. Inci- 
dentally an eye trouble necessitated the application of 
leeches by his oculist to the temples, resulting in im- 
mediate relief to his nerve symptoms which had hitherto 
baffled all treatment. Six months later his old symp- 
toms returned but the reapplication of leeches and the 
‘withdrawal of blood from the brain vessels was as 
successful as in the primary instance. 

Uric Acip NeEvrastuHEntA. Brain workers often suffer 
from a series of perplexing symptoms which baffle the 
skill of their medical advisers. Such sufferers are 
usually good livers and lead sedentary lives. With 
such, insomnia, headache, mental depression, backache, 
and dyspepsia are prominent signs. 


THE CAUSE AND CURE. 43 


When Alexander Haig, of London, issued his work, 
‘¢ Uric acid as a factor in the causation of disease,’’ he 
attempted to make many problems clear which had 
heretofore remained unrecognized. His uric acid 
theory is briefly as follows: Uric acid occurs in the 
blood in traces during health. It is derived chiefly 
from foods, and persons who eat an excess of food and 
« take little exercise, produce an excessive quantity of 
* uric acid, which, accumulating in the blood, gives rise 
toa train of symptoms. The blood being naturally 
alkaline, holds the uric acid in solution, but, if from 
any cause, the blood becomes acid, it can no longer 
hold the uric acid in solution and consequently the 
latter is precipitated. Now, the joints, muscles and 
ligaments are favorable sites for the precipitation of 
uric acid, hence those who suffer from uric acid poison- 
ing complain of muscular pains in the back and joint 
stiffness. This theory, while primarily fascinating, 
soon became the subject of critical analysis with results 
inimical to its tenability. It was shown that uric acid 
was absolutely non-irritating to the tissues and could 
be injected in large amounts into animals, as well as 
administered in their food with no toxic results 
whatever, in other words, wric acid itself does not 
produce disease. 

It is not the retention of uric acid in the system 
which produces the so-called urze acid diathesis but 
the presence of certain products, the result of deficient 
oxidation. These products are known as the purin or 
alloxuric bases, like xanthin, guanin, adenin, etc. They 
are highly toxic, and are normally burned in the body 
through the process of oxidation and are finally con- 
verted and eliminated as uric acid, a very harmless 
product. The toxic substances in question are derived 


A4 THE BLUES :—NEURASTHENIA. 


in part from food and in part from the worn out body 
cells. 

W oods- Hutchinson" clearly defines our present status 
regarding the uric acid theory in referring to the nature 
and causation of gout, viz: ‘‘ A toxemia of varying 
causation, usually of gastro-intestinal origin, accom- 
panied by the formation of an excess of urates, this 
excess of urates being due to the breaking down of the 
leucocytes and fixed cells in the attempt to neutralise 
the poison—in other words, being the measure of the re- 
sisting power of the body tissues. The formation and 
introduction of the toxins, be it well understood, are 
by no means confined to the gouty; it is only the 
nature of the resistance of the body to.them that gives 
the character of gout.”’ 

This carries us to a consideration of gastro-intestinal 
diseases as a cause of neurasthenia, which I will include 
under the caption of Awto-towemic neurasthenia. 

Avto-toxemMic NrurastHEeNtA. In general, auto-tox- 
emia refers to poisoning of the organism superinduced 
by poisons generated within that organism, a condition, 
in other words, of self infection. Self-infection may 
occur from the following causes: 1. Retention in the 
body of certain substances destined for excretion (A wto- 
intoxication of retention). 

2. Absorption of substances from normal or ab- 
normal cavities of the body developed from putrefac- 
tion or fermentation (Auto-intoxication of resorption). 

3. Substances developed from disturbances in the 
cells and secretions of organs (histogenic auto-intoxica- 
tion). | 

4. Poisoning, the result of toxine absorption deve- 
loped by micro-parasites (auto-intoxication of infection). 

The second variety of auto-intoxication of which re- 


THE CAUSE AND CURE. 4B 


sorption from the gastro-intestinal canal is the most 
conspicuous example and which is best understood will 
occupy our attention. 

GASTRO-INTESTINAL AUTO-INTOXICATION. —Bouchard 
was one of the first to show that man is constantly 
standing, as it were, on the brink of a precipice. Every 
moment of his life, he runs the risk of being overpowered 
by poisons generated within his system. The healthy 
-and unhealthy body is a receptacle and laboratory of 
poisons. Self poisoning is only inhibited by the activity 
of the skin, kidneys and bowels. These poisons are 
normally manufactured in our gastro-intestinal canal, 
and were it not for the action of the bowels, kidneys 
and skin, many of us would succumb to auto-intoxica- 
tion. Aside from the excretory organs which promote 
the excretion of the poisons, the alimentary canal and 
the liver are endowed with functions capable of render- 
ing innocuous many of the toxic substances. 

The proponents of this theory maintain that in 
health, auto-intoxication does not occur, either because 
sufficient of the toxic material is not absorbed and is 
rapidly excreted, or if absorbed, the poisons are made 
inert by the action of the liver, blood and tissue cells. 
On the other hand, self infection occurs in disease of 
the gastro-intestinal mucous membrane which facili- 
tates the entrance into the blood of the toxic sub- 
stances, or because the liver and the tissue cells are 
incapable of making them innocuous. 

The symptoms of auto-intoxication are difficult of 
enumeration, simply because the recognition of the 
affection itself is difficult. 

Observation however has taught us, that the toxic 
products are capable of producing local symptoms, viz: 
various digestive disturbances and general disturbances 


46 THE BLUES :—NEURASTHENIA. 


of the nervous system. Such signs may duplicate the 
symptomatic picture of neurasthenia with profound de- 
pression, mental disturbances, epilepsy, locomotor 
ataxia and mental exaltation. This varying symptom- 
atic picture depends on the nature of the toxic sub- 
stances absorbed, some exciting, others depressing the 
nervous system. Schroeder von der Kolk, some years 
ago, demonstrated that acute, confusional insanity was 
associated with fecal accumulation in the colon. 

As already stated, it is difficult to associate many of 
the symptoms with gastro-intestinal poisoning and 
here the results of treatment could offer us some assist- 
ance. In a few instances, we know that manifold 
nervous symptoms have subsided after free evacuation 
of the bowels, but in my own observations, where 
there was every reason to suspect intestinal auto- 
toxemia, the results of treatment were quite unsatis- 
factory. 

The treatment in question was that which is con- 
ceded to be the best for intestinal auto-toxemia: 1. An 
exclusively milk diet which reduces to a minimum the 
introduction of poisonous food products. 2. Daily ir- 
rigation of the stomach and bowels. 38. Purgatives. 
4. Intestinal antiseptics. I am constrained to con- 
clude, that the auto-intoxication theory, while of great 
scientific value and hints at many possibilities in the 
future is not sufficiently developed at the present time 
to prove of much practical value to the neurasthenic. 

AxspominaL NevurastHEentA. There are a number of 
abdominal affections which have been cited as causes 
of neurasthenia, and I have grouped them all under 
the caption of abdominal neurasthena. The belief 
that the'abdominal cavity was responsible for many 
diseases, notably, hypochondriasis is of ancient origin. 


THE CAUSE AND CURE. 4” 


The term hypochondriasis, originated from the supposi- 
tion that its cause was resident in the hypochondriac 
region, owing to the feelings of distress and uneasiness 
which prevailed there. Broussais (1772-1838) advo- 
cated, as his most powerful treatment, the application 
of leeches to the abdomen and as many as thirty to 
fifty were applied at a single seance. This was hirud- 
inomania with a vengeance. In 1785, Johann Kamp, 
published a work, entitled, ‘‘For physicians and 
patients, a new method for the radical cure of perni- 
cious diseases, specially hypochondriasis, which have 
their origin in the abdomen.’’ He refers to many nery- 
ous diseases which were unquestionably of abdominal 
origin, and his treatment consisted in the main of 
enemas made from decoctions of herbs. 

Voetsch, in 1874, published his work on ‘ copros- 
tasis’’ (hardened fecal matter in the intestines), and 
recites in detail the histories of fifty-eight patients 
with manifold disturbances in different organs that 
were directly attributed to habitual constipation. 

In 1885, Glénard issued an important work, in 
which he attributed neurasthenia to enteroptosis, a con- 
dition in which there was a prolapse of one or other of 
the abdominal organs. The symptoms described by 
him and known as Glénard’s disease occurred in the 
following order of succession: 1. Debilty and _lassi- 
tude. 2. Sensations of uneasiness, weight, dragging, 
craving, emptiness, etc., in the abdomen. 38. Symp- 
toms of dyspepsia. 4. Nervous symptoms. The re- 
searches of Glénard were of great importance, but 
subsequent observers did not confirm his conclusions in 
their entirety. The conservative opinion now is, that 
prolapse of the abdominal organs may occur without 


48 THE BLUES :—NEURASTHENIA. 


neurasthenic symptoms and that neurasthenia may 
occur without gastric symptoms. 

Dunin,® in 1891, demonstrated that habitual con- 
stipation is associated with a train of neurasthenic 
symptoms, but he cautions, and in my experience 
wisely, against the regular employment of purgatives 
which only aggravate the symptoms. 

Federn,* in 1894, published a monograph, in 
which he attempted to show, that nervous symptoms 
(neurasthenia), contrary to accepted doctrines, are by 
no means dependent on a nervous system faulty by 
heredity, but that they are caused primarily by in- 
testinal disturbances. The latter cause an increase in 
the blood pressure and to this must be attributed the 
nervous symptoms. In this increased blood pressure, 
he argues, there is a mechanic irritation of the tissues 
and organs, for when the blood pressure is reduced to 
normal all nervous manifestations cease. In the ma- 
jority of neurasthenics, there is apartial intestinal atony 
with or without constipation or intestinal catarrh. 

Dysprpsta AND NeurASTHENIA. Most writers admit 
that dyspepsia is frequently an associated condition of 
neurasthenia, but its definite relation to the disease in 
question is a matter of doubt. Some maintain that 
neurasthenia may produce a particular kind of stom- 
ach disturbance, others, that if stomach disturbances 
develop they are merely manifestations of a neurasth- 
enic condition. The latter view is based on the prin- 
ciple, that in health all the organs work harmoniously : 
One is dependent on the other for the normal perform- 
,ance of its work. If one suffers they all suffer, a 
vicious circle being thereby established. 

Some one organ, however, it may be the stomach, 
heart or liver, usually bears the brunt of nervous ex- 


4 


THE CAUSE AND CURE, 49 


haustion. Why this is so, is difficult to say, other 
than by supposing that every person like Achilles has 
some vulnerable spot. ‘Some persons when they have 
a ‘‘nerve storm,’’ center all theirabnormal sensations 
in the heart, others in the stomach, others in the head. ° 

Still others contend that neurasthenia in a certain 
proportion of cases is the result of the gastric disorder. 
The latter contention is, however, difficult of definite 
solution. Those who support the latter theory, notably 
Savill,” claim that dyspeptic disturbances often pre- 
cede the symptoms of neurasthenia and ergo neuras- 
thenia may be provoked by dyspepsia. Who can tell, 
however, if the dyspeptic disturbances were not the 
initial symptoms of neurasthenia ? This much is true, 
however, that gastric derangements, in fact all ab- 
dominal affections complicating neurasthenia are at- 
tended by depression of spirits, circulatory, and many 
vague nervous disturbances; nutrition is seriously em- 
barassed and there is a decided falling off in weight. 

How a digestive disturbance operates is a matter of 
conjecture only. There is necessarily a defective nutri- 
tion of the nerve apparatus and there is also an in- 
creased elaboration of toxic products. I believe that 
many cases of neurasthenia and I wish particularly to 
be understood in my contention, not all cases, have an 
abdominal origin: that in many cases, whatever the 
nature of the ailment, the neurasthenia may be referred 
to a defect in the nerve apparatus which controls the 
supply of blood in the abdominal cavity, and further- 
more, that the condition is eradicable by the adoption 
of certain simple methods based on scientific principles. 
The form of neurasthenia in question, I will call 
splanchnic neurasthenia, which will be the subject of 
discussion in succeeding chapters. 


50 THE BLUES :—NEURASTHENIA. 


SUMMARY. 


1. A congenital degenerate nervous system is not 
the primary factor in neurasthenia, although such a 
system will react more easily to irritants which pro- 
duce the disease. { 

2. Deranged bodily functions are often responsible | 
for the neurasthenic state, and their recognition de- 
mands unusual diagnostic acumen on the part of the 
physician. The latter will heed the trite remarks of 
Sir William Savory : ‘‘ Consciousness of one’s ignorance 
may do much to avert the errors of carelessness, and 
he who has confidence in his own judgment should 
of all men be most careful in inquiry.”’ 

3. The uric acid theory of neurasthenia is most fas- 
cinating but faulty, and even the latter could be condoned 
were definite results achieved by treatment executed 
in accordance with the theory. The patient is not a 
theoretician but an utilitarian. He visits his physi- 
cian with a definite object in view, to get well, and 
mere theories will not influence him. The uric acid 
theory, it must be conceded, at least inculcates the 
doctrine of moderation in eating and selection of food, 
a doctrine which is most salutary in all diseases. 

4, The theory of gastro-intestinal auto-intoxication, 
while endowed with a modicum of truth, is in a practical 
sense undeveloped and furnishes no definite clue to the 
symptoms of self-poisoning nor to its treatment. 

5. Gastro-intestinal disturbances, of whatever nature, 
seriously compromise the integrity of the nervous 
system, either by inducing neurasthenia or aggravating 
it if it exists. 


THE CAUSE AND CURE. 51 


6. There is a form of nervousness which I have 
designated as splanchnic neurasthenia, which is capable 
of cure, and the treatment is based on definite scientific 
principles. 

This special form of neurasthenia has heretofore es- 
caped recognition. 





CHAPTER IV. 


THE GENERAL AND SPECIAL SYMPTOMS OF NEURAS- 
THENIA. 


MOTOR DISORDERS.-SENSORY DISTURBANCES.— EYE SIGNS— 
EAR SIGNS.—BRAIN SIGNS.— HEART SIGNS AND THE PULSE.— 
PULMONARY ANEMIA.— STOMACH AND INTESTINAL SIGNS.— 
SEXUAL SIGNS.—FORMS OF NEURASTHENIA.— DIAGNOSIS 
AND PROGNOSIS OF NEURASTHENIA. 


THe GernerAL Symptoms. These may be divided 
into: 1. Motor disorders. 2. Sensory disturbances. 
3. Disturbances of the special senses. 

Motor Disorpvers. uscular fatigue is a constant 
sign. Muscular contraction is excited through the 
nervous system by nerve impulses which reach the 
fibres of the muscle. Such contractions may be volun- 
tary, automatic or reflex, but, in all instances, they 
predicate a discharge of nerve force from a nerve 
center. When a muscle contracts it transforms an 
equivalent amount of energy. The latter consists in 
oxidizing food substances contained in its fibers or 
burning them at a relatively low temperature. The 
chief food-substances consumed. by a contracting muscle 
are glucose or grape sugar, glycogen and fat. Fatigue 
of muscle is essentially caused by the consumption of 
material necessary for contraction and the storing up 
in the muscle of waste products produced by its own 


54 THE BLUES :—NEURASTHENIA., 


activity. Some people naturally tire more easily than 
others owing to the fact that the waste products re- 
sponsible for the fatigue in the one are less easily re- 
moved or accumulate more readily. Massage of the 
muscles rapidly removes the evidence of fatigue, simply 
because the waste products from the muscles are washed 
away into the circulation by this maneuver. The 
fatigue in neurasthenia probably has its origin in the 
nervous system and only indirectly in the muscles; for, 
if we pursue the same argument which physiologists 
accept as the cause of muscular fatigue, viz: the 
accumulation of waste substances, it is reasonable to 
assume, that a like condition prevails in the nervous 
system. If one tests the strength of the muscles in 
neurasthenia by means of the dynamometer, while the 
muscles may show a diminished response, it is by no 
means proportionate to the diminished vigor experienced 
by the patient. 

Marcet,’® has shown that the time during which an 
individual can sustain a voluntary muscle contraction is 
determined by the endurance of the brain centers en- 
gaged in the act of volition, rather than by that of the 
muscles themselves. The very moment these centers 
are exhausted the muscle contraction gives way. An- 
other fact developed by the same writer, and as it 
seems to me, an important one which can be applied 
to neurasthenia is, that volition can be fatigued when 
exerted in imagination as well as in actual muscle 
effort. 

Muscular tire in the neurasthenic is expressed by 
general muscular weakness, lack of endurance, a tired 
feeling, a feeling of never being rested and a sensation 
of extreme weariness on rising in the morning. In 
severe cases, patients remain in bed for indefinite 


THE CAUSE AND CURE. 55 


periods, having assured themselves by aid of their 
morbid imagination that they are incapable of any 
kind of muscular effort. When fatigue symptoms be- 
come exaggerated, they become painful and are de- 
scribed by the patient as aches. 

Tremor. This is often brought out by the slightest 
muscular effort and Lemarcq, found it present in eighty- 
five per cent. of neurasthenics. The tremor is a fine 
one and present most often in the hands, but may be 
general, including the knees, legs and the closed eye- 
lids. In pronounced cases, the fine tremor may be 
substituted by twitching of the muscles, and they may 
become so pronounced in the face and tongue, that on 
seeing such individuals for the first time, one is con- 
strained to think of general paresis. All the reflexes 
are exaggerated. 

Sensory Distursances.—/eadache is a common sign. 
It may be constantly present or evoked by any men- 
tal or muscular effort or some emotion. In most 
instances, the headache is not really described as an 
ache, but a feeling of heavy weight or constriction 
about the head. Some describe the sensation of a 
closely fitting lead cap on the head. Charcot described 
the head-sensation as the ‘* casque neurasthenique,’’ a 
feeling as though the patient were wearing a tight- 
fitting helmet. The head sensation may be also de- 
scribed by the patient as a feeling of pressure or ache 
in definite regions, notably the base of the brain, the 
top or front of the head or atthe temples. Still others 
experience a heaviness or throbbing and a sensation as 
if wind or water were running under the scalp. The 
neurasthenic head sensations usually occur when the 
patient wakes up and last during the day to disappear 
on retiring. 


56 THE BLUES :—NEURASTHENIA. 


BacKAcHE, or a sensation of weariness, is a fre- 
quent symptom and the older writers referred to this 
symptom as ‘‘ spinal irritation.”’ 

If the signs of so called ‘‘ spinal irritation ’’ are pro- 
nounced, the feeling of intense weariness prevents the 
patient from sitting or standing for any length of time. 
Women suffer more frequently than men from the back 
sensations, and a favorite location for the tenderness 
in women is at the extreme end of the spine (Coccyg- 
odynia) 

All cases of backache are not necessarily of neuras- 
thenic origin but are often due to a faulty spinal 
attitude. Thus the attitude of children with ‘‘ round 
shoulders’’ will substitute ligamentous for muscular 
support. Deformities of the foot, like flat foot, will 
conduce to pain in the back owing to the faulty atti- 
tude assumed by such persons. 

Patns in THE Lruss. These are sensations various- 
ly described as hot flushes, tingling, cold, numbness, 
stiffness, soreness, etc., In any and all parts of the 
body. In some instances, the pains become fixed in 
some definite region, as over the heart or stomach, a 
condition described by Blocg as ‘‘topoalgia’’ or local 
neurasthenia. !" 


SPECIAL SYMPTOMS. 


Eye Stens. Vision is never seriously affected. An 
early sign is a blurring of the vision on using the eyes 
for any length of time and which may become so pro- 
nounced that the patient is unable to perform any 
work requiring the use of the eyes for any length of 
time. Often the vision becomes veiled and things — 
look strange and unreal. Patients often complain ~ 


THE CAUSE AND CURE. BY 


of a defect in visual memory, i.e., they see some 
- familiar object, it may bea person or a thing, but 
they do not remember it with their normal facility. 
It must be conceded, in the hght of modern observa- 
tion, that there are cases of neurasthenia, may I call 
them ‘‘ ocular neurasthenias,’’ which owe their origin 
solely to some easily remedied eye defect. Such defect 
may be due to an error in refraction or to defects in the 
ocular muscles. 

The remote effects of eye strain may include not 
only neurasthenia but vertigo, migraine, chorea, and 
epilepsy. The refractive condition of the eye is rarely 
normal, and no muscles of the body are subjected to 
such excessive strain as the ocular muscles. If one 
wishes to appreciate the effects of eye strain, all that 
is necessary 1s to wear for a few minutes the glasses of 
another person suffermg from astigmatism. In the 
recognition of an ocular defect, the task of the physician 
is by no means ended. He must determine whether 
the eye-defect is alone responsible for the symptoms or 
whether they are aggravated by other conditions, as 
defective hygiene, bad habits, etc. ; he must treat the 
nervous system after correction of the ocular defect, 
and he must direct the patient to an oculist and not an 
optician. Even all oculists are not specially skilled in 
correcting errors of refraction and many relegate this 
important matter to assistants or execute it in a per- 
functory manner. 

Drooping of the lids, inequality of the pupils or ex- 
cessive mobility of the iris are symptoms which have 
been observed in neurasthenia. It has been noted in 
testing the visual field in neurasthenia, that when an 
object is brought from without into and across the 
field of yision that it is seen in wider range than when 


58 THE BLUES :—NEURASTHENIA. 


it is placed in the center of vision and carried gradually 
outward toward the periphery. This is known as 
‘« Koerster’s shifting type,’ and is the reverse of the 
normal condition. | 
Ear Stans. Abnormal ringing, singing, whistling 
and roaring sounds may be heard although hearing 
may be intact. 

As a rule, these signs are associated with some 
actual disease of the middle ear, in elderly people, 
with degenerative changes in the blood vessels, and in 
young persons, with some abnormal state of the blood. 
Ilearing in neurasthenics is often hyperesthetic and 
they show excessive sensibility to noises, the slightest 
noise startles them. Even melodious music is borne 
with intolerance. 

Brain Siens. The capacity for mental work becomes 
diminished. Any mental effort is attended by a sense 
of fatigue and distress. Fixing the attention on any- 
thing is deficient and often impossible, and the ability 
to originate ideas or to think intelligently or connectedly 
becomes lessened, or is abolished entirely. There is 
lack of will power, and this deficiency is frequently ex- 
pressed by vacillation or indecision. Alental irritability 
is another sign added to the cerebral manifestations. 
The patient becomes annoyed at little things which be- 
fore failed to disturb his equilibrium. There is loss of 
memory. Ideas do not occur with the usual vigor and 
patients affirm that ‘‘they cannot think straight.”’ 
The fear of insanity is common. Attracted by their 
symptoms, they become introspective, misconstrue 
their sensations and develop phobias or morbid fears. 
Morbid fears rarely become insane delusions. Fear 
in neurasthenics develops as a result of weakness or 
loss of courage. 


THE CAUSE AND CURE. 59 


Some fear to be alone, some fear darkness, others 
narrow or high places, others crowds and still others an 
open space, etc. Some fear dirt or infection by dis- 
ease. A neurasthenic recognizes the absurdity of his 
fears and is able to dispel them, whereas the hypoch- 
ondriac regards such fears as actual conditions and 
cannot be convinced to the contrary. 

Morbid fears are technically described as follows: 

1. Pathophobia, fear of disease. 

2. Claustrophobia, fear of narrow spaces. 

3. Photophobia, fear of light. 

5. Mysophobia, fear of defilement. 

Imperative conceptions and morbid impulses are not 
unknown conditions in neurasthenia. The former re- 
fer to ideas which the patient knows are absurd, but 
which nevertheless occur to him and dominate his 
thoughts, and often direct his actions. When he is 
unable to recognize the absurdity of his conception, it 
becomes a delusion. 

A Morsip Lvectse is an irresistible desire to commit 
an act which the patient knows to be wrong. 

Dounisnep Arrection for those dear to him is 
another sign which often distresses the patient. Es- 
quirol observes that, ‘‘ moral alienation is the first 
step to madness.’? The patient becomes irritable, 
fault-finding and resentful. He dreads meeting ac- 
“~aaintances or people. Ie approaches his daily task 
with a sense of weariness. Ile becomes emotional and 
lachrymose on the slightest pretext. He recounts the 
history of his illness to every one who will lsten and 
often seems to delight in so domg. Asa rule, he re- 
gards the future with distrust. His feeling of mental 
depression pictures all sorts of horrible things. He 
fears that he will never get well or that he will become 


60 THE BLUES :—NEURASTHENIA. 


insane or paralyzed. He cannot bear to read the 
morning papers lest some accident, or murder or sudden 
death may distress him. 

SLEEPLESSNESS 1S one of the earliest signs. Some- 
times there is difficulty in falling asleep, or the sleep 
is constantly disturbed. Occasionally the sleep is 
sound and deep, yet the patient awakens in the morn- 
ing unrefreshed and often feels more depressed than 
upon retiring. On closing the eyes in bed, there is, 
at times, sudden jerking of the legs, or a feeling as of 
falling. When dreams disturb the sleep, they indicate 
that the latter is not sound, but partial. In dreams, 
the brain is in part awake; the will is dormant and 
the imagination runs riot with incongruous and fantas- 
tic images. When many brain centers are active, 
dreams are consistent and coherent, while, when few 
centers are working, they are unreal and extravagant. 
Dreams are evidence of unsound sleep. The dreaming 
period, in health, rarely occurs until the time for 
awakening approaches. If the dreaming period comes 
on early, there is some disorder present in the body 
which retards the complete rest of the brain. Attempts 
have been made to classify dreams, but such classifica- 
tions, from a psychologic standpoint, are purely 
arbitrary. 

RESTLESSNESS 1S a frequent svmptom. The patients 
keep continually moving and are always ‘‘on the fid- 
get.’’? If they are in one place, they want to be some- 
where else, in fact, they really do not know what 
they do want. 

Vertico or a feeling of dizziness or faintness is not 
an unusual symptom. It is a disturbance of conscious- 
ness, manifested by apparent movement of external 
objects, or of the subject himself. If the person 


THE CAUSE AND CURE. 61 


himself appears to move, it is known as subjective, and 
if objects move as objective vertigo. 

Vertigo experienced when reclining, and disappearing 
on rising, is known as horizontal vertigo. 

The attacks are usually subjective, short in duration 
and unaccompanied by nausea. While the sensation is 
usually experienced while the patient 1s up and about, 
some persons feel the sensation while in bed as though 
they were sinking through it. Vertigo is a cause for 
alarm in many patients. There is another form of ver- 
tigo occurring in neurasthenics, which is essentially 
psychogenetic. It is a sudden sensation of insecurity, 
a fear of falling or loss of consciousness. In such in- 
stances there is never any real vertigo, nor do the pa- 
tients fall or lose consciousness, and the condition is 
essentially a mental disease. Vertigo is occasioned by 
such a multitude of conditions that a diagnosis of ‘‘ neu- 
rasthenic vertigo’’ is never warranted until other 
conditions which are apt to cause it are carefully 
excluded. 

Harr Siens. Heart Palpitation is a frequent 
symptom. 

Palpitation means that the patient is conscious of his 
heart’s action. A conscious knowledge of any organ 
constitutes disease of that organ, not necessarily or- 
ganic, but more often functional disease. A person 
with a healthy heart is not conscious that he has such 
an organ. In the mild forms of palpitation only a 
fluttering or sinking feeling is experienced. In the 
more severe forms, the heart beats violently against 
the chest, the arteries throb and the action of the 
heart is increased as many times as 150 pulsations per 
minute. In nervous palpitation, the face becomes 
flushed, and after the attacks large quantities of urine 


62 THE BLUES :—NEURASTHENIA. 


are passed. An attack may last only a few minutes 
or may continue for hours. Palpitation is most often 
caused by some digestive disturbance or may result 
from emotions or prolonged muscular or mental efforts. 
‘¢Rumpt’s symptom,’’ is sometimes present. It 
consists of making pressure over some painful point in 
the body which will bring up the pulse from 80 to 90 
to over 100, and it will remain there for one or two 
minutes. The heart may be unusually rapid in action 
(heart hurry), slow, irregular or intermittent. There 
may be pains localized in the heart region which radi- 
ate down the arms (false angina pectoris). Cardiac 
disturbances are most frequent in women, in young 
persons and in those addicted to the inordinate use of 
tobacco, tea, coffee and alcohol. In many neurasthe- 
nics, the heart gives unquestionable evidence of weak- 
ness, and this isa factor which must be taken into 
serious consideration in the treatment of the patient. 
Tre Purse. Various attempts have recently been 
made by clinicians to endow the pulse in neurasthenia 
with certain characteristics, but thus far all efforts in 
this direction have been practically futile. My studies 
in arterial tension in this disease show that the pulse 
is move often of low than high tension, and when the 
latter exists it is found in full blooded individuals, in 
whom some form of intoxication may be surmised. 
Erben,!® after studyinga largenumber of neurasthen- 
ics observed that the customary increase in the pulse 
rapidity that follows the movements of the body did 
not take place if the patient bent far forward, or, as 
Ortner pointed out, if they bend their heads backward. 
After either posture, it was observed that the pulse, 
after continuing its rhythm for from four to fifteen 
beats, there was a sudden retardation of the pulse, 


THE CAUSE AND CURE. 63 


which continued for about sixteen beats, after which 
the pulse gradually attained its former rapidity. 

Vasomotor Disrursances. When the vasomotor 
center is weakened or irritable, flushing and pallor of 
the skin occur at irregular intervals, specially in women, 
with cold hands and feet, throbbing noises or fullness 
in the head, spots before the eyes, dizziness, etc. 

Tue Urine. This is usually normal, but, after a 
. ‘nerve storm,’’ it is passed in large quantities, of a 
pale color and of low specific gravity. Phosphates 
may be present in excess as well as endican or owalate 
of lume, when the case is one of sexual neurasthenia. 

Tue Temperature is usually normal, even though the 
patients experience flushing or burning cutaneous 
sensations. 

Tue Broop is usually normal, although there are 
neurasthenics, specially women and young girls, who 
show an anemic condition of the blood. I have 
show elsewhere ® that anemia is often associated with 
insufficient lung development, aform of anemia which 
I have designated as pulmonary anemia.* In this 
anemia of pulmonary origin there is not necessarily a 
diminished number of red blood corpuscles nor of hemo- 
globin, the element lacking being oxygen (Anoxemza). 
Individuals, the subject of anoxemia, resist all the con- 
ventional forms of treatment, but when treated by aid 
of respiratory exercises to achieve lung development, ° 
the anemia disappears. Much benefit is derived from 
respiratory exercises in the treatment of neurasthenia, 
and the improvement noted proceeds commensurately 
with the oxygen-carrying capacity of the blood color- 
ing matter. Other factors may have been at work in 
improving the nervous symptoms, for we know that 


* Appendix, note 1. 


64 THE BLUES :—NEURASTHENIA, 


healthy lung ventilation means an increased flow of 
blood and lymph in the nervous system, and this means 
an augmented supply of oxygen, improved nutrition and 
removal of waste products. 

Stomacu Siens. The more I observe dyspepties, 
the more certain is my conviction that nervousness is 
responsible for the majority of cases. We are a na- 
tion of dyspeptics, owing to our ceaseless and intense 
living methods. Repair is not commensurate with 
waste, and there comes a time to many of us when 
our functions must suffer. All the organs of the body 
in health work harmoniously; one is dependent on the 
other for the normal performance of its work. If one 
suffers, they all suffer, yet some one organ, 1t may be the 
heart, the stomach or the liver, usually bears the brunt 
of nerve exhaustion. 

Nervous indigestion is a frequent complication of 
nerve strain. The appetite may be unimpaired and even 
voracious. At other times, the mere thought of food is 
repugnant. Often the food eaten lies like a heavy 
weight. The patient belches and is apt to bring up a 
sour fluid, giving rise to heartburn. The tongue may 
be perfectly clean throughout the disturbances of diges- 
tion. The day has waned when the physician, after 
casting a furtive glance at the tongue, feeling the pulse 
and asking a few desultory questions about the stomach, 
proceeds to prescribe what has been facetiously called a 
“shotgun ” prescription; embodying pepsin and acid 
to increase digestion, an alkali to correct acidity, a tonic 
to promote digestion and a purgative to move the bowels. 
Such a prescription is as much a contradiction as the 
“whiskey cocktail” deseribed by the perturbed French- 
man, “a little whiskey to make it strong, a little water 


THE CAUSE AND CURE. 65 


to make it weak, a little lemon to make it sour, a little 
sugar to make it sweet, and then you say, here’s to you, 
and you drink it yourself.” The scientific physician 
of to-day takes nothing for granted; he places the pa- 
tient on a “ test meal,” after which, he withdraws the 
contents of the stomach and subjects it to chemie analy- 
sis. Having ascertained the ingredients of the gastric 
juice, he is ready to fulfill his duties as an up-to-date 
practitioner, and prescribe accordingly. In the major- 
ity of cases of nervous dyspepsia, chemic analysis shows 
no anomaly, and digestion is found to have been com- 
pleted within the normal time limit. The latter facts 
are alone characteristic of nervous dyspepsia. Were the 
digestive trouble of a nature other than nervous, there 
would be decided changes in the gastric juice, and in 
the character of the digestion. Nervous dyspeptics in- 
stinctively discover that it is not wise to eat too much 
when nervous or excited, for it is at such a time that 
gastric signs predominate. 

IntrestrnaL Siens. The chief sign is constipation. 
Torpidity of the bowels may run in families. Seden- 
tary habits, coupled with excessive eating and a disre- 
gard to the call of nature, as well as the character of 
the food eaten, are common causes of constipation. In 
neurasthenia, the muscular tone of the bowels suffers 
and it becomes incapable of moving the fecal matter 
onward into the rectum. There are some persons who 
are persistently constipated without suffering any in- 
convenience. A patient once told me, in detailing his 
symptoms, that as far as his bowels were concerned, 
they were in perfect condition, as they moved regularly 
onee a week. The majority of persons, however, com- 
plain that unless they have a daily evacuation they 


66 THE BLUES :—NEURASTHENIA. 


suffer from languor, headache, loss of appetite and de- 
pression. So potent an influence does a free evacuation 
have on the condition of well-being that even Voltaire 
was induced to write: ‘‘ Those persons who are in good 
position . . . whose bowels are freed by an easy, regu- 
lar, peristaltic movement every morning as soon as they 
have breakfasted . . . those who are thus favored by 
nature are mild, affable, gracious, kind. A no from 
their mouth comes with more grace than a yes from the 
mouth of one that is constipated.” 

A recent German writer has collected a large num- 
ber of cases of neurasthenia dependent wholly on con- 
stipation and the evil results thereof. He contends, and 
his contention cannot be questioned, that the bowels 
normally manufacture poisons which, when absorbed, 
influence the delicate nervous system. Hypochondriacs 
are usually constipated, and so are the insane. One 
of my patients, who is an habitual sufferer from consti- 
pation, and has periodic “‘ nerve storms,” finds imme- 
diate relief after taking a saline purgative. The physi- 
ology of defecation is practically as follows: The fecal 
matter formed in the large intestine sets up peristalsis, 
which moves the fecal mass through the large bowel, 
dropping it into the rectum. At the latter point “a eall 
of nature ”’ takes place, and evacuation is the result. If 
no response is made to this “ call” by the individual, 
whether through laziness or attention to other duties, 
the watery portion of the fecal mass is absorbed, passes 
into the circulation and intoxicates the nervous system. 
Persons who suffer from this auto-intoxication have a 
muddy skin, dark rings under the eyes, cold extremities, 
an unpleasant taste in the mouth, dark, offensive and 


THE CAUSE AND CURE. 67 


insufficient bowel movements and a heavy urine, which 
leaves a deposit on standing. 

Mucous ENtTeErRiTis is an intestinal neurosis oe- 
curring specially in hysteric females and those of a 
highly neurotic constitution. 

The most important symptom associated with severe 
colicky pain is the passage at varying intervals of long 
threads of mucus, which are imperfect casts of the 
eut. The disease is chronic and obstinate to treatment. 

SExUAL Siens. When the symptoms of neurasthenia 
predominate in the sexual apparatus, we speak of sexual 
neurasthenia. In neurasthenia the sexual power is 
usually very much diminished, either by incomplete 
erections, premature ejaculations or night emissions. 
Married men find this weakness a source of much mental 
suffering, and the constant fear of impotency prompts 
them to seek medical advice. It is, without doubt, true 
that the majority of functional troubles of the sexual 
organs are of a neurasthenic nature. Whatever the 
changes may be in his sexual apparatus, the unfortunate 
sufferer is inclined to exaggerate them by a vivid imagi- 
nation or the perusal of quack advertisements. Normal 
ingredients of the urine, such as phosphates and urates, 
passed by such persons, are declared by charlatans, to be 
seminal fluid. Although seminal fluid may be passed 
during urination or defecation, it is nevertheless a rare 
occurrence. 

Involuntary seminal emissions in a healthy unmar- 
ried man, occurring at different periods, must always 
be regarded as an evidence of good health. It is only 
when the emissions are followed by depression, vague 
pains in the head, and a feeling of exhaustion, that they 
are to be regarded as harmful. Some individuals suffer 


68 THE BLUES :—NEURASTHENIA. 


no inconvenience from night emissions, occurring even 
as often as several times a week, whereas, in others, 
a simple emission once a week, or even less often, is 
attended by the signs previously noted. Seminal emis- 
sions may be the cause of nerve depression, not the con- 
sequence of the loss of semen, but from the nerve 
exhaustion following. More often, the emissions are 
the result of nerve depression. It frequently happens 
that sufferers from seminal emissions attribute their 
trouble to the habit of self-abuse. While the habit is 
unfortunately well nigh universal among both sexes 
and animals, and frequently attended by dire results, 
the latter have, no doubt, been greatly exaggerated. 

Spermatorrhea, or the passing of semen with the 
urine or during defecation, 1s indicative of grave de- 
bility of the sexual apparatus. It is usually the result 
of neglected or improperly treated seminal emissions. 
Many cases of so-called spermatorrhea, it must be em- 
phasized, are really urethral discharges, other than 
semen. The microscope alone can determine the nature 
of the discharge. 

Impotence signifies one of the following conditions. 
1. Deficiency of desire and power. 2. Deficiency of 
power with increased desire. 3. Abnormal erectile 
power, known as priapism, in which there is no dis- 
charge of semen. Very often the impotence is imag- 
inary, a form known as psychical impotency. It is 
strange that people are not better educated in regard 
to their sexual functions. All they learn is of a sug- 
gestive nature by the reading of erotic literature and 
quack advertisements. Among the prominent symp- 
toms of sexual neurasthenia, are: dimness of vision, 
back pains, mental depression and defective memory, 


THE CAUSE AND CURE. 69 


dyspepsia, palpitation of the heart and dizziness. In 
women, sexual neurasthenia presents symptoms similar 
to those of man, although they occur with less frequency. 
Some suffer from nocturnal orgasms, accompanied by 
dreams, and they awake feeling nervous, depressed and 
exhausted. In married women, the sexual appetite may 
be increased at first, but it rapidly disappears, to be fol- 
lowed very often by distaste or even disgust. 

Tur Sexuat Hypocuonpriac. This unfortunate 
creature, boy, girl, man or woman, usually lives a life 
of profound despondency, the result of a real or fancied 
disturbance of the sexual organs. Such cases demand 
a true explanation of the disorder, but when the morbid 
state of mind is encouraged by the charlatan, only dire 
results follow. There is no sufferer to whom truth is 
more repellant than the sexual hypochondriae, in fact, his 
morbid fear is a delusion which he wishes to have veri- 
fied. The sexual hypochondriac may be the victim of 
one of the following disorders: Involuntary seminal dis- 
charges, impotency, masturbation, or syphilophobia. 

Involuntary seminal discharges are quite natural and 
occur in all persons who lead a correct and continent 
life, and are not unlike menstruation occurring in 
women at periodical intervals. The “ night emissions ” 
are not necessarily the involuntary discharge of semen, 
but are often made up of a fluid derived from the pros- 
tate gland. Some persons secrete a larger quantity of 
prostatic fluid than others, hence it is quite within the 
limits of health for such individuals to have involuntary 
discharges at more frequent intervals. Then, again, 
the character of food eaten has a notable influence on 
the amount of seminal or prostatic fluid secreted. The 
milky character of the urine in the sexual hypochon- 


=) 


70 THE BLUES :—NEURASTHENIA. 


driac is not semen but phosphates, a fact which is made 
evident when a little acid is added to the urine, result- 
ing in the complete disappearance of the milky character 
of the urine. The mucilage-like fluid observed at the 
head of the penis, after stool, is often of no consequence, 
consisting, as it often does, of the secretion of the pros- 
tate gland. 

Impotency, or fondly ealled, “ lost manhood ” by the 
advertising quack, is in most instances an imaginary 
condition. ‘True manhood finds no index in the vigor 
of the sexual apparatus. The more man approaches the 
condition of brute creation, the more powerful is his 
sexual instinct. . 

As man and woman ascend the seale of moral and 
social life, there is less inclination for the performance 
of the sexual act. Such individuals are both potent 
and impotent at times. The best type of a married man 
is only potent in the presence of his consort. IEf he 
demonstrates this potency toward another, his moral 
standard is as low as the negro who commits rape as 
often as occasion permits. An indefinite number of un- 
foreseen conditions, ike mental and physical fatigue, 
disgust, worry and anger, conduce to make every man 
impotent at times. The fear and timidity which possess 
the newly married are evidences of morality and not 
sexual weakness. It has been estimated by a trust- 
worthy statistician that at least 60 per cent. of young 
husbands fail in the first attempt after marriage. There 
are many individuals who are impotent, owing to their 
overwhelming fear of contracting some disease. There 
are persons who manifest impotency toward certain 
women, but who are fully capable of performing the 
act with others. 


THE CAUSE AND CURE. iat 


Unnatural practices are bound to be followed by im- 
potency. The sexual act, when aroused by artificial 
means, finds no response when invoked by natural 
methods. Sexual psychopathy, or the attainment of 
sexual desire by unnatural means, is a stigma of degen- 
eration manifested in persons who have inherited or ac- 
quired a defective nerve organization, and is common 
among the insane. 

MaAsTURBATION may conduce to severe disturbances in 
the mental and physical health, but as the habit is 
stopped at an early period of life, as soon as the inde- 
cency of the habit is explained, no possible consequences 
ever arise. We must all encounter a period in life when 
there is a conflict between the passions and one’s better 
self, but the latter is usually the victor in the combat. 
It is not an exaggeration to maintain, that, in the ma- 
jority of instances, the evils arising from masturbation 
practiced moderately, and for a short period in youth, 
are largely mental, developed from the-loss of self-re- 
spect and the sense of unmanliness. 

Forms or NeurastHenta. Beard makes the follow- 
ing classification of neurasthenia: 

1. Cerebral neurasthenia (cerebrasthenia, cerebral 
exhaustion ). 

2. Spinal neurasthenia (myelasthenia, spinal ex- 
haustion). 

Digestive neurasthenia (nervous dyspepsia). 
Sexual neurasthenia (sexual exhaustion). 
Traumatic neurasthenia (traumatic exhaustion). 
. Hemi-neurasthenia (hemi-exhaustion). 
Hysterical neurasthenia (hysterical exhaustion). 

A more modern classification is that of Dana.2° Here 
the types of neurastheriia are made dependent upon 


TTD St oo 


42 THE BLUES :—NEURASTHENIA. 


the age, the sex, and the hereditary endowments of the 
individual. 

Primary NervrastuentaA. Neurasthenia appearing 
at the adolescent period is likely to be associated with a 
primarily weak and nervous constitution. Mental 
symptoms predominate, assuming the character of hypo- 
chondriasis with fixed ideas or morbid fear. Sexual 
ideas and symptoms likewise predominate. 

Hysrero-NEvURASTHENIA. Occurs in women asso- 
ciated with hysteria. Much pain along the back, gives 
rise to the condition known as “ spinal irritation.” 

AcqQuIrRED NEURASTHENIA AND LiruemiaA. Here, the 
element of heredity is less marked, while the extrinsic 
causes of neurasthenia dominate the situation, viz.: 
Excessive eating, drinking, shocks, injuries, poisons, 
syphilis, and gouty tendencies. This form occurs dur- 
ing the active period of life. 

Curmactrertc. This develops in the middle life and 
is associated with arterial degeneration and a dimin- 
ished resistance of the body generally. Physical weak- 
ness is greater, associated with vasomotor disturbances, 
and a tendency to melancholia. 

Traumatic Nerurastuenta. After injuries, how- 
ever slight, but associated with fright and emotional 
disturbance, the patient develops all the symptoms of 
neurasthenia. The latter may consume several weeks 
in developing, and do not always immediately follow the 
injury. Such cases usually end in litigation and the 
worry, incident to the trial, will aggravate the symp- 
toms. After the trial the patient may get well, but this 
is, by no means, the invariable rule. 

Sprinat Irriratron. In this form, to the picture of 
neurasthenia is added painful symptoms related chiefly 


THE CAUSE AND CURE. (ee 


to the sensory nerves of the spine. The pain predomi- 
nates in the lower part of the back and also in the back 
of the neck. Exertion intensifies the pain. Relief and 
comfort seem only to be secured by rest in bed, so they 
go there and remain. 

The spinal processes are sensitive to pressure and the 
painful points vary at each examination. The arms 
and legs are exceedingly weak, incapacitating the sub- 
ject from any kind of exertion. 

The duration of the affection may extend into years 
or their invalidism may become permanent. While the 
symptoms are essentially referred to the spine, the real 
trouble has its seat in the brain, which mental sensitive- 
ness aggravates. 

NEURASTHENIA WITH Frxep Ipra. This form is as- 
sociated with a fixed idea of a depressing character relat- 
ing either to fright or remorse, and worries and harasses 
the patient through every moment of the waking hours. 
The fixed idea may center itself on an intense fear of 
death or that there is an incurable heart or kidney 
trouble. Such patients may for a time be persuaded 
to release themselves from their obsession, but it soon 
recurs, despite all their efforts. | 

Awnetopatuic NeurastHenta. Here the vasomotor 
symptoms predominate. Pulsation or beating of the 
blood-vessels involves the whole body. 

Grave NevrastHentaA. This is characterized by a 
severe and serious type of exhaustion, both mental.and 
physical. Emaciation is a prominent sign. Only tem- 
porary benefit results from treatment, and many of the 
patients pass into permanent and hopeless invalidism. 
Men who have reached or passed the middle period of 
life are the usual subjects, and the condition suggests a 
premature senescence of the nervous tissues. 


v4. THE BLUES :—NEURASTHENIA. 


Diagnosis. There are several affections closely re- 
lated to neurasthenia, and the boundary line is very 
often so severely drawn that.a differentiation from them 
can only be determined by the results of treatment, time, 
the judgment of the physician, and the willingness of 
the subject to patiently submit himself as an object of 
study, of which time is the essence. A better under-. 
standing will thus be mutually established between the 
physician and the patient, for the latter, like all neu- 
rasthenies, will agree with Avicenna, ‘I prefer confi- 
dence before art, precepts and all remedies whatever.” 
“Medical art,’ says Hippocrates, “consists of three 
things: the patient, his malady, and the physician.” 
Moxon’s witty paradox is also apposite. ‘‘ It is quite as 
important to know what kind of a patient the disease 
has got, as to know what sort of a disease the patient 
has got.” 

The diagnosis of neurasthenia, or its allied affec- 
tions, is only warranted after a most painstaking exami- 
nation of the patient. It is always wise in the exam1- 
nation of the subjects to regard neurasthenia merely as 
a symptom rather than a disease, and to seek for some 
local disturbance which reflexly instigates the nervous 
symptoms. This statement may not receive the sanc- 
tion of conventionalism, but evidence is rapidly acecu- 
mulating in support of this contention. The following 
affections suggest differentiation: 1. Hysteria, 2. Hy- 
pochondriasis. 38. Melancholia. 4. General paresis. 
5. Insanity. 

No physician can afford to depend on any single 
method in diagnosis. Pathognomonie signs are as un- 
common as specific drugs in disease, and the truly 
skilled diagnostician is he who is catholic and eclectie¢ 


THE CAUSE AND CURE. 75 


in the selection of his methods, and the most painstak- 
ing in their application. 


THE PATHOGNOMONIC SYMPTOMS OF THE 
VARIOUS AFFECTIONS. 


NervrRASTHENIA. Fatigue is the primary and funda- 
mental symptom, relieved by rest and intensified by 
© exertion. There is always a cause, notably over use and 
abuse of functional activity abetted by a nervous sys- 
tem, which responds readily to irritants, but does not 
recover in like ratio. The perverse reaction of the irri- 
table, weakened nerve apparatus is characterized by sen- 
sory, motor, vasomotor and psychie disturbances. The 
prognosis is favorable. 

Hysterta. Neurasthenia in men is in many re- 
spects the equivalent of hysteria in women, modified 
by sex, and with symptoms less developed. In hysteria 
there is diminished control over the emotions, and the 
symptoms occur in paroxysms (nerve storms) although 
in the inter-paroxysmal period, the stigmata of the af- 
fection are nearly always evident, viz: hysterogenic 
zones, areas of anesthesia, hyperesthesia, ete. There is 
a tendency to practice deception, a morbid craving for 
sympathy, and a perversion of the moral nature. The 
' affection is of indefinite duration, although the hyster- 
ical temperament lasts a lifetime. 

Hypocuonprrasts. Confined almost exclusively to 
the male. An isolated mental disturbance with a 
groundless fear of disease, which has no real existence, 
but exists only in the imagination of the patient. Hy- 
pochondriaes are bodily well with few or no stigmata 
of neurasthenia. The cause is usually a solitary or 
sedentary life. There is an hereditary taint. It begins 


76 THE BLUES :—NEURASTHENIA. 


gradually and runs an even course of indefinite dura- 
tion. The patient does not relax in his endeavors to 
seek a remedy for his imaginary affection. 

Metancuours. In the early stages of this affec- 
tion there is a close resemblance to neurasthenia, and 
the latter has been frequently defined as an abortive 
form of melancholia. The rapid emaciation, frequent 
pulse, persistent insomnia, extreme mental depression 
with delusions and suicidal tendencies are signs which 
distinguish this affection from neurasthenia. 

GENERAL Paresis. The symptoms of. neurasthenia 
in the primary stage are often responsible for errors in 
diagnosis. In paresis, however, the mental disturb- 
ances are more pronounced. Failure of memory, with 
expansiveness of ideas, inability to write and spell cor- 
rectly, tremor of the face, hands and tongue, and un- 
equal pupils are signs which suggest paresis. 

Folsom’s diagnostic description of the early stages of 


paresis is worthy of citation: ‘‘ It should arouse sus- | 


picion if, for instance, a strong, healthy man, in or near 
the prime of life, distinctly not of the nervous, neurotic 
or neurasthenic type, shows some loss of interest in his 
affairs or impaired faculty of attending to them; if he 
becomes varyingly absent-minded, heedless, indifferent, 
negligent, apathetic, inconsiderate, and although able to 
follow his routine duties, his ability to take up new work 
is, no matter how little, diminished; if he can less well 
command mental attention and concentration, concep- 
tion, perception, reflection, judgment; if there is an 
unwonted lack of initiative, and if exertion causes un- 
wonted mental and physical fatigue; if the emotions are 
intensified and easily change, or are excited readily 
from trifling causes; if the sexual instinct is not rea- 


THE CAUSE AND CURE. us 


sonably controlled; if the finer feelings are even slightly 
blunted; if the person in question regards with placid 
apathy his own acts of indifference and irritability and 
their consequences, and especially if at times he sees 
himself in his true light, and suddenly fails again to 
do so; if any symptoms of cerebral vasomotor disturb- 
ances are noticed, however vague or variable.” 

Insantry. Savill,?! in his excellent treatise, refers 
to a mental disorder which is special to neurasthenia. 
The recognition of such a mental state is of the utmost 
importance, as such patients require no restraint nor 
asylum treatment. It differs from true insanity In six 
respects : 

1. Marked bodily weakness precedes and accom- 
panies the disorder. 

2. The condition is curable by appropriate measures 
after a duration of a few weeks or months. 

3. The most prominent feature of the mental condi- 
tion is mental weakness. Delusions and hallucinations, 
as a rule, are absent. 

4, ies is difficult to make it correspond with a of 
the types of insanity found in asylums. 

5. The mental symptoms vary from day to day, and 
lucid intervals occur from time to time, during which a 
casual observer might find nothing wrong with them. 

6. There is no family history of insanity. 

Prognosis. As a rule, neurasthenia is a curable dis- 
ease. The duration and permanency of cure is a mat- 
ter based on the individual treated and the judgment 
of the physician in the application of his resources. 
The individual must be regarded from the following 
standpoints: 

1. History of heredity. 


78 THE BLUES :—NEURASTHENIA. 


2. His nerve capital. 

3. His environment. 

4, [is habits. 

First of all, heredity plays only a subordinate role 
in neurasthenia, provided the patient can be made con- 
scious of the fact, that nerve health is a matter of indi- 
vidual effort in the direction of rigid regard of hygienic 
laws. If there is an abundance of reserve nerve capital, 
a few weeks or months, will suffice to restore the indi- 
vidual to a condition of well-being. Hnvironment and 
habits determine the permanency of a cure and relapses. 
If the patient subjects himself after recovery to the 
causes which induced his disease, he soon suffers from 
another attack of nervous breakdown, drifts into a state 
of chronic invalidism or becomes an habitue of some 
drug habit. An attack of neurasthenia cripples a nerv- 
ous system, and predisposes to other attacks, so that 
eternal vigilance becomes the keynote of health. Asa 
rule, however, the neurasthenic enjoys a long life, for 
he is ever conscious of his past experience, which guides 
him safely along the pathway of hygienic living. Of 
consumption, one has truly said, ‘‘ If I knew what pro- 
duced it, I could cure it.’? Just so with neurasthenia, 
we know what will produce it, but do we give due regard 
to the details in the patient’s life history, any one of 
which, if not eliminated, will suffice to perpetuate the 
disease ? Our standard of progress is not evidenced by 
the introduction of new drugs, the delirium of which 
threatens toannihilate rational therapeutics. Reliance 
on the healing power of nature is an evidence of erudi- 
tion. It affords the discerning physician an oppor- 
tunity of knowing what not to do, and enables him to 
apply the highest principles of the therapeutic art, 


THE CAUSE AND CURE. 79 


SUMMARY. 


1. fatigue and the proneness to it is the primary 
and essential sign. of neurasthenia. It is relieved by 
rest and instigated by exertion. 

2. Neurasthenia is a functional disease, and the ex- 
clusion of organic disease is absolutely essential before 
the diagnosis of neurasthenia is warranted. Disease is 
the sphinx of medicine. The interpretation of the signs 
constitutes diagnosis, which is the Cidipus of medicine. 
The translation may be correct, partially correct or 
wrong. In all three instances, the result, as far as the 
patient is concerned, will, as a rule, be the same, pro- 
vided no treatment is instituted. ‘To treat a disease, 
other than by expectant methods, where the diagnosis is 
in question, is adding insult to injury. 

3. The objective are subsidiary to the subjective 
symptoms in neurasthenia, for it is more often necessary 
to know “ what kind of a patient the disease has got, 
as to know what sort of a disease the patient has got.” 

4. The patient who expects the physician to make 
an immediate diagnosis, is a believer in miracles and, 
carrying his absurdity to extremes, predicts like results 
from treatment. Such a patient should be admonished 
to consult Providence and not a physician, for he is as 
mad as his nerves. 

5. Neurasthenia lies on the borderland of insanity, 
and if the patient is not even mildly insane, his symp- 
toms are often severe enough to make him so. 

6. The prognosis is dependent on a multitude of 
factors: the patient, his habits, the cause of his disease, 
the severity of reaction on the part of his nervous sys- 
tem, etc. As arule, the prognosis is good, for the logical 


80 THE BLUES :—NEURASTHENIA. 


tendency of a pathologie condition is always toward a 
physiologic ending. 

“ But, after all, I am a man, and not a theorem. A 
system cannot suffer, but I suffer. Logic makes only 
one demand—that of consequence; but life makes a 
thousand; the body wants health, the imagination cries 
out for beauty, and the heart for love; pride asks for 
consideration, the soul yearns for peace, the conscience 
for holiness; our whole being is athirst for happiness 
and for perfection ; and we, tottering, mutilated, and in- 
complete, cannot always feign philosophic insensibility ; 
we stretch out our arms toward life, and we say to it 
under our breath, ‘ Why—why—hast thou deceived 
me?’ ”’—Henri Freperic AMIEL. 


‘And, I may append to the foregoing, because thou 
hast deceived nature. 


CHAPTER V. 
THE GENERAL TREATMENT OF NEURASTHENIA. 


OBJECTS OF TREATMENT.—ELIMINATION OF FACTORS 
CONDUCIVE TO THE DISEASE.——-TREATMENT OF THE 
DISEASE. — CLIMATE. — TREATMENT OF THE SYMP- 
TOMS: INSOMNIA, HEART, STOMACH, INTESTINAL, AND 
SEXUAL SYMPTOMS.—HYPNOTISM AS A MODE OF CURE. 


Tue physiologic treatment of neurasthenia in general 
aims to fulfil the following objects: 1. The removal of 
the cause; 2. The treatment of the disease; 3. The 
treatment of symptoms. 

Under physiologic treatment is comprised the use of 
remedial measures, other than the use of drugs, by 
which the natural powers of the human body are so- 
licited to combat disease. These natural measures can- 
not be supplanted by the most skilful drugging, and 
should be employed by the progressive physician to the 
exclusion of drugs in such a disease as neurasthenia. 
The monumental work of Solomon Solis Cohen, entitled 
“A System of Physiologie Therapeutics,” recently is- 
sued in eleven octavo volumes, is an enduring tribute 
to the value of physiologic therapeutics. 

ELimiInation oF Factors Conpuctve to Neuras- 
THENIA. ‘The ideal aim of the physician is unquestion- 


ably the removal of the cause of neurasthenia, but even 
81 


82 THE BLUES :—NEURASTHENIA. 


though this is possible, there yet remains the disease, 
the effect of the cause, which must claim attention. 

Sleep is, without doubt, the natural restorative of a 
fagged brain. The writer, when suffering from brain 
tire, finds more relief by three day’s absolute rest in bed 
than by a sojourn of two weeks in the country after the 
conventional manner. Sleep is, however, a restorative 
that cannot always be summoned at will. The inventor, 
speculator, student and business man must seek mental 
recreation. The brain worker who seeks diversion and 
does so constrainedly defeats the object of such diver- 
sion. The diversion adopted must be agreeable. Travel 
is often suggested as a method of mental recreation, but 
it is often done in such a perfunctory way that the vic- 
tim returns to his habitual routine work more exhausted 
than recuperated. ‘ They may change their skies, but 
not themselves.’ Indulgence in extraneous literature, 
the cultivation of a fad, some regulated exercise, like 
golf, bicycling, hunting, ete., are excellent means of 
diversion. Employment prevents melancholy—it is 
restful to the body. Inaction, idleness and the constant 
pursuit of pleasure, simply encourage premature old 
age. Above all things in seeking physical exercises as a 
means of diversion, one must be sure to avoid physical 
overwork. Physical exhaustion is naught else but nery- 
ous fatigue, for every physical act is the result of 
nervous energy. The limit of physical exercise is fa- 
tigue. Rational exercise is not nerve exertion, but a 
gradual and progressive use of muscles, diverting the 
blood from the overtaxed brain throughout the entire 
body. Neurasthenics, who over-exercise, develop poi- 
sons equally as injurious as those generated by brain 
strain, 


~~ 


THE CAUSE AND CURE. 83 


Rewier For Worrment. “ Worry, not work, 
kills.” Worry in persons previously unaccustomed to 
great responsibilities is one of the greatest factors in 
the premature loss of health and life. Worry, grief, 
passion and fretting are powerful nervous shocks. ‘They 
arrest the functions of digestion and impair the bodily 
functions. 

SELF-ConTROL is a resourceful palladium against 
nervous prostration. The latter affection is rarely en- 
countered in those who have acquired a knowledge of 
self-overnment. I refer to neurasthenia, incited by 
worry, fretting, and emotional disturbances of any kind. 
From what has preceded, we already know that there 
are forms of neurasthenia which develop and are be- 
yond the control of the individual. Man has been de- 
fined as “a creature looking before and after.” He 
must know what his powers and limitations are before 
he ean intelligently exercise them to the benefit of his 
mind and body. Man, by his unbridled indulgence of 
his passions, is continually paying the penalty for his 
sacrifice of self-control.’ We must, therefore, guard 
ourselves from drifting upon the shoals of nervous 
degradation. When nervous breakdown once oceurs, re- 
covery is only possible to a certain extent, and relapses 
are frequent. As Courtney put it: “ Hardly any of 
them come out of the conflict unscathed, and though 
many recover sufficiently to cope with the ordinary 
duties and trials of life, they are never quite capable 
of weathering its real storms.” 


THE TREATMENT OF THE DISEASE. 


Tue Rest Cure. In a little book, “ Fat and Blood 
and How to Make Them,” Dr. Weir Mitchell has cre- 


a 


84 THE BLUES :—NEURASTHENIA., 


ated a new era in curative medicine, and the victims 
of nervous prostration and hysteria are his debtors. He 
has simplified a task heretofore almost impossible of 
attainment, viz.: The cure of a pronounced ease of 
nervous prostration. It would be ridiculous to affirm 
that all cases can be cured by the rest cure, any more 
than to say that any method of treatment, yet devised, 
will cure all cases of the disease to which it is adapted. 
This much one ean conscientiously and conservatively 
say—it cures and benefits a large percentage of cases 
where the dominant causative factor is overwork, result- 
ing from a perennial unrest of body and mind, while 
in a small percentage of cases, 1t aggravates rather 
than benefits the disease. For instance, in splanchnic 
neurasthenia, as well as in other forms, the rest cure 
alone, gives only temporary relief, insomuch as the 
therapeutic manceuvres incident to the rest cure increase 
the resistance of the nervous system, and make it less 
responsive to a multitude of irritants. 

The cardinal points of the rest cure are isolation of 
the patient, rest with exercise and over-feeding. A rest 
cure attempted at the patient’s home is rarely attended 
with suecess, hence the necessity of absolute isolation, 
that is, the execution of the cure away from home to ob- 
tain the necessary control of the patient. The most im- 
portant element of treatment is moral control. Loving 
and sympathetic relatives can never appreciate the na- 
ture of the patient’s symptoms. There are some pa- 
tients who thrive poorly on absolute isolation, in which 
instances they are occasionally permitted to see at in- 
tervals their friends and members of their family. An 
intelligent nurse is indispensable—a poor nurse is worse 
than useless. ‘The details of the method are essentially 





THE CAUSE AND CURE. 85 


as follows: The patient is confined to bed, and under 
no circumstances is allowed to get up, to read, or write. 
The patient is even fed by the nurse, the object being 
to secure perfect passivity of mind and body. Absolute 
rest is not always enforced, the method being modified 
to suit the individual case. It is the rule for patients 
“to affirm that it is impossible for them to remain in bed 
continuously, and it is but natural that they should 
make this statement, for their extreme restlessness only 
announces the instability of their nervous system. Con- 
trary evidence is soon forthcoming after absolute rest 
in bed and the manifestations of nerve irritability are 
subdued. It is then that they share the enthusiasm of 
the poet, when they proclaim: “ O, bed! O, bed! de- 
licious bed! That heaven upon earth to the weary 
head!” 

After rest in bed for several weeks the patient is al- 
lowed to sit up. To facilitate digestion and build up 
nutrition during the rest cure, massage and electricity 
are employed daily. Massage and electricity give exer- 
cise to the unused muscles, improve the circulation and 
promote the absorption of nourishment. Insomuch, as 
nearly all neurasthenics suffer from indigestion, and 
consequently imperfect body nourishment, diet is a most 
important factor in the rest treatment. Great discretion 
must be exercised by the physician in the selection of the 
proper diet, and when this is accomplished, it is sur- 
prising what prodigious quantities of food can be taken 
by the patient undergoing the rest cure. The improve- 
ment in nutrition is manifested by increase in weight, 
which may be all the way from 10 to 40 pounds. In 
many individuals hydropathic treatment is employed, 
with water at varying degrees of temperature, and it is 


86 THE BLUES :=NEURASTHENIA. 


surprising to note the sedative and tonic influences of 
cold water when the patient is accustomed to its use. 
Tue Partiat Rest Trearment. In cases of mild 
neurasthenia, and for patients who cannot give up their 
entire time to the full rest treatment, which is often 
the case in men, the following partial rest treatment 
may be employed: On waking in the morning, a cup 
of cocoa is taken, and the patient should remain in bed 
twenty minutes longer; after this, the patient rises and 
takes a cool or cold sponge or shower bath, after which 
the skin is vigorously rubbed with a rough towel; fol- 
lowing the bath, breakfast is taken, after which the 
patient should lie down for an hour and remain at 
absolute rest, without reading. At 10:30, a glass of 
milk is taken, when the patient may go out for a walk 
or drive or attend to business. At 1 o’clock luncheon 
or dinner is taken, after which meal the patient should 
lie down for an hour. In the afternoon any recreation 
may be taken, or attention paid to business until 6: 30, 
when dinner or supper is taken, followed by rest for an 
hour. At 9:30 the patient should retire for the night. 
Massage should be taken once a day; before rising in 
the morning, after the morning cup of cocoa, or in the 
evening before retiring. A wineglassful of malt should 
be taken with each meal, and if the patient has impovy- 
erished blood, some simple iron preparation should be 
taken. In conclusion, “ It is reiterated,” says Courtney, 
“that affections of the brain and nervous system are in 
greater measure preventable than those of other parts; 
consequently the mental and nervous salvation of the 
individual is, practically speaking, to a very marked 
extent, within his own hands, and may be worked out 


THE CAUSE AND CURE. 87 


by him through rigid attention to the guidance of hy- 
gienic laws.’’ 


THE TREATMENT OF SYMPTOMS.—INSOMNIA. 


Tue Tuerortes oF SLEEP. The anemic theory sup- 
poses that during sleep there is a decreased amount of 
blood in the brain. The toxc theory supposes that in 
consequence of the wear and tear of the body tissues, 
waste products are generated which have a benumbing 
influence on the brain cells, which preside over the 
senses. A strong proof of the latter hypothesis is ad- 
duced by the following observation of Striimpell: A 
young man had lost all power of sensation except in the 
right eye and the leftear. When the former was coy- 
ered by a bandage and the latter stopped by a plug 
the brain of the subject was practically isolated from 
the outer world, and the invariable result was genuine 
sleep. ‘‘The substance of the brain,’’ says Ham- 
mond, in ‘Sleep and Its Derangements,’’ ‘‘is con- 
sumed by every thought, by every action of the will, 
by every sound that is heard, by every object that 
is seen, by every odor that is smelled, by every pain- 
ful or pleasurable sensation, and soon each instance 
of our lives witnesses the decay of some portion of 
its mass and the formation of new material to take its 
place.’’ 

During sleep the physical and mental functions are at 
rest. Sleep is more essential to life than food. In sleep, 
muscular relaxation is absolute, and the amount of air 
inspired by a normal man is one-seventh of that used 
during similar periods of quiet wakefulness. The pulse 
is less rapid, and the brain contains less blood. The 


88 THE BLUES :—NEURASTHENIA. 


first few hours of sleep are the most valuable, because 
they are most profound. 

Amount oF Steep Necessary. In the time of 
Solomon, the twenty-four hours were divided into three 
parts—eight hours for labor and occupation, eight hours 
for rest, refreshment and recreation and surcease of all 
labor, and eight hours for sleep. The object of sleep is 
the reconstruction of overworked organs, and it would 
be too arbitrary to determine the number of hours neces- 
sary for sleep, for its real value lies more in the inten- 
sity of sleep than on its duration. Again, the amount 
of sleep necessary is commensurate with the mental and 
physical exercise of the waking hours. Eight hours 
of a disturbed, dreamy sleep is barely the equivalent 
of two hours of a deep, dreamless sleep. or this rea- 
son, we can easily understand why men of the greatest 
mental activity are usually the briefest sleepers. Fred- 
erick the Great required only five hours’ sleep, and Pitt 
only three hours. Brown says, that at four years, twelve 
hours’ sleep are needed; at fourteen years, ten hours; 
at seventeen, nine and one-half hours; then seven or 
eight hours during adult life. In old age, continuous 
sleep is rare and the necessity less; but frequent naps 
during the day and night make up the average. In cold 
countries more sleep is required than in warm climates. 
The length of time a person can live without sleep is 
about three weeks. 

Conpirions Favortina Srterp. <A well ventilated 
room, cool, dark and quiet. A comfortable bed with 
a moderate amount of covering. Mental worries and 
intense thoughts interfere with sleep. Sleep is a power- 
ful habit. A person who awakens at a certain hour for 
several successive nights, eventually establishes the habit 





THE CAUSE AND CURE. 89 


of awakening at that hour. The habit should be culti- 
vated of retiring and awakening at a definite hour. 

THe Cause oF [ysomnia on SLEEPLESSNESS. Prof. 
See divides all causes of insomnia into: 1. Psychical, 
and 2. Physical. The causes of psychical insomnia in- 
clude cases of sleeplessness dependent on mental emo- 
tion, to thought, worry, that is, to causes not directly 
dependent on organic disease. Young, the well-known 


author of “ Night Thoughts,” was presumably thus af- 
flicted— 


‘From short as usual and disturbed repose, 
I awake. How happy those that wake no more ; 
I awake emerging from a sea of dreams 
Tumulttous, where my wrecked despondent thought 
From wave to wave of fancied misery 
At random drove, her helm of reason lost !” 


The worries of the student, the merchant, the specu- 
lator, homesickness and disappointments are of this 
order. In the treatment of such cases, the physician, is 
often powerless to act. 

‘Who shall minister to a mind diseased ; 
Pluck from the memory a rooted sorrow, 
’Rase out the written troubles of the brain, 
And with some sweet oblivious antidote 


Cleanse the stuffed bosom of that perilous stuff 
Which weighs upon the heart?” 


Puystcat Causes. Every deviation of health is 
characterized by disturbance of sleep, but in most cases 
where a vicious sleep habit is established, it tends to 
persist. Among the chief causes are: 1. Brain strain; 
2. Organic diseases of the brain and arteries; 3. Stom- 
ach and intestinal diseases; 4. Irritation of the sexual 
organs; 5. Poisonous substances (toxic insomnia). 


90 THE BLUES :—NEURASTHENIA. 


Tue Insomnia oF Bratn Srrary. This means in- 
crease in the supply of blood to the brain, eventuating 
in cerebral congestion. It is an undoubted fact, that the 
brain strain of severe mental labor is measurably les- 
sened by an adequate amount of physical exercises. 
Physiologists and hygienists have shown this to be true, 
yet we must be cautious in going to the other extreme, 
taking too much physical exercise; for otherwise, the 
poisonous substances generated by muscular fatigue only 
tend to excite the brain and tend to insomnia. 

Tue Insomnia oF Organic DIsbASES OF THE BRAIN 
AND Arteries. Whenever the nutrition of the brain is 
compromised by actual disease, then insomnia of an ag- 
gravating and persistent character results. When the 
insomnia is caused by brain congestion, there is flushing 
of the face, redness of the eyes, giddiness, confusion of 
ideas, and sometimes stupor. Insanity may commence 
with obstinate insomnia. 

Tur Iysomnia or Stomacu anp IntTEstrnaL Dis- 
EASE. In indigestion, toxic substances are developed 
which irritate the brain and prevent sleep. In many in- 
stances, the accumulation of gases in the stomach and 
intestines by pressing on important organs, notably the 
heart and lungs, induce sleeplessness indirectly. Some 
persons sleep best, if, before retiring, they take a light 
repast; others, on the contrary, would find such a pro- 
cedure an indiscretion, certain to be followed by in- 
somnia. Sleep after eating is a salutary procedure. It 
draws the blood from the brain to the stomach, and thus 
facilitates digestion. 

Toxtc Insomnta. Insomnia induced by the indis- 
criminate use of poisonous substances like alcohol, cof- 
fee, tea, tobacco, ete. Not infrequently the inhibition 


THE CAUSE AND CURE. 91 


of any one of these substances will often cure an in- 
tractable insomnia. 

Symproms or Insomnr1a. In the insomnia of neu- 
rasthenia, the sleep is often interrupted by dreams of 
the most abhorrent nature, which seem to dominate the 
person in the wakeful state. As a result of insomnia, 
many neurasthenies are restless, excited, querulous and 
irritable. 

TREATMENT oF Insomnia. It has been truly said 
that if sleep and hope should be taken from man, he 
would be the most miserable being in existence. Much 
ean be obtained by obeying the laws of hygiene. Atten- 
tion must be directed to a minute investigation of all 
the bodily functions to ascertain the fundamental con- 
dition, of which insomnia is a mere manifestation. We 
possess many drugs which, when prescribed with discre- 
tion, may be regarded as harmless, yet drugs should only 
be used as a last resort, for any drug which induces sleep 
by overpowering the body is not entirely without danger. 

The bromides are the safest hypnotics, and so are, 
lupulin, valerian and spirits of lavender. The use of 
other hypnotics is fraught with danger, and should never 
be prescribed until one has exhausted every other sim- 
pler means to produce sleep, for of all beings the neu- 
rasthenic is specially lable to suecumb to a drug habit. 

Generally speaking, an adequate amount of physical 
exercise is necessary in all sufferers from insomnia. 
Nothing is more conducive to sleep than exercise taken 
in the open air. Some diversion for the brain worker 
may be found in change of scene and society. ‘“‘ Seeing 
that too much sadness has congealed your blood, and 
melancholy is the nurse of frenzy, therefore, have 
thought it good for you to hear a play, and frame your 


99 THE BLUES :—NEURASTHENIA. 


mind to mirth and merriment, which bars a thousand 
harms and lengthens life.” 

No detail should be neglected in ascertaining the 
cause of insomnia. Tea or coffee should not be taken 
at the evening meal, and tobacco should not be used, at 
least some hours before retiring. A glass of warm milk, 
or a cup of hot bouillon before retiring may prove bene- 
ficial in inducing sleep. Some derive sleep by taking a 
glass of beer or malt extract before retiring. If the 
sufferer from insomnia be a literary man or student, all 
intellectual effort should be stopped at least an hour 
before retiring, and the interval filled in with some 
extraneous dull reading. When this fails, no intellec- 
tual work should be done after supper, reserving that 
work for the early morning hours. Some cases of in- 
somnia only yield after a complete change of scene free 
from excitement and sightseeing. Active exercise be- 
fore retiring, with dumb-bells, pulley-weights or Indian 
clubs, followed by a tepid or warm sponge bath, often 
induces healthful and refreshing sleep. Climate is an 
essential consideration in those who suffer from insom- 
nia. Warm climates are soothing, and cool climates 
stimulating to the nervous system. On account of the 
cool nights in the mountainous districts, refreshing sleep 
can often be obtained. Some find benefit by residing at 
the seashore. California has a marvelous diversity of 
surface and corresponding varieties of climate. While 
the climate of southern California is especially favor- 
able for consumptives or persons with heart or kidney 
diseases, northern California is better adapted to build 
up the neurasthenic. The winds that sweep through the 
Golden Gate often make the summer climate of San 
Francisco somewhat harsh, yet there are districts in 


THE CAUSE AND CURE. 93 


the immediate vicinity of San Francisco free from 
winds and fogs, and there is no city in the world which 
has such environs. About 125 miles from San Fran- 
cisco, at Monterey, is the famous Del Monte hotel. 
Here the climate is sedative and equable, and _ per- 
mits of an out-door hfe throughout the year. The tem- 
perature rarely rises above 80° F. The temperature 
of the water averages 52° I. in January and 60° F. in 
July. Neurasthenics, who suffer from insomnia, obtain 
much relief at Monterey, where art has conspired with 
Nature to make this one of the garden-spots of the world. 

HyprotuEerapry is a valuable adjunct in the treat- 
ment of insomnia. Schneller’s experiments proved con- 
clusively that ice apphed to the head of an animal 
eaused contraction of the blood vessels of the brain, 
which persisted for a short time after the ice was re- 
moved. The brief application of cold or warm water 
to the surface of the body is stimulating, but if pro- 
longed, depressant. A cool sponge bath, or even a cold 
plunge before retiring, will provoke sleep. The sec- 
ondary effect of cold to the skin, is to dilate the blood- 
vessels, which draws the blood away from the brain. 
Many sufferers find relief in a prolonged warm bath 
before retiring, the effect being sedative on the nervous 
system. Others find equal benefit in a hot foot bath. 
Some find relief in a Turkish bath, followed by a gen- 
eral massage. The wet pack has done heroic service for 
many nervous persons. It is used as follows: A sheet 
having been wrung out of cold water, is thrown over the 
patient from neck to ankles, and over this several dry 
blankets, with a hot-water bag to the feet and a cold 
wet cloth to the forehead. The patient remains in the 
pack from half an hour to an hour, and is then vigor- 


94 THE BLUES :—NEURASTHENIA. 


ously rubbed with a coarse, dry cloth until the skin 
glows. The wet pack may be given every night or sey- 
eral times a week. 

Hot compresses, consisting of flannels wrung out of 
hot water, applied to the abdomen and covered with dry 
flannels, are often efficacious. A hot bag may be sub- 
stituted. The cold douche to the head, or a shower 
bath to the head and spine, are frequently serviceable. 

MassaGe is often of service in insomnia, when every 
other hygienic measure fails. 

Some persons can induce sleep by having recourse to 
the hop pillow, which should be moistened with spirits 
before being placed under the head of the patient. 
Among drugs, bromide of potash is the least harmful. 
For an adult, 30 grains may be taken in sweetened water 
before retiring, and repeated in an hour, if necessary. 
It is especially useful in nervous eases. 

ExLectricrry, when properly employed, especially in 
the form of static electricity, is almost an indispensable 
remedy in insomnia. Contrary results often follow its 
injudicious application. The Galvanic current has a 
tendency to make some persons sleepy, and is to be ap- 
plied in the evening. The Faradic current makes most 
people wakeful. Electricity is especially useful in in- 
somnia of brain strain and alcoholism. 

Hypnotism is likewise an indispensable agent when 
judiciously employed. 

A common procedure for inducing sleep is energetic 
and frequently repeated opening and closing of the eye- 
hds. Auto-suggestion is often of service. The patient 
should go to bed with the firm conviction that sleep is 
bound to follow. One may imagine observing all the 
phenomena incident to sleep in another person. The 


THE CAUSE AND CURE. 95 


reading of dull books or concentrating the mind on some 
blank and wearying picture makes the mind receptive 
to only one suggestion, viz, sleep. 
** A flock of sheep that leisurely pass by 
One after one; the sound of rain and bees 


Murmuring ; the fall of rivers, winds and seas, 
Smooth fields, white sheets of water and pure skies.” 


Dreams. These are frequent concomitants of the 
neurasthenie state. Dreams are not recalled when sleep 
is profound, but occurring at the natural time of wak- 
ing they are remembered. Dreams are made up of ideas 
and emotions, which have no laws of association nor 
coherence. In ancient times, dreams were regarded 
with much significance, but the attempts of the scientist 
to classify them has been attended with indifferent re- 
sults. Diseases of the liver are supposed.to be asso- 
ciated with dreams of disturbed forms. 

Niagutmarr. This may prove indicative of an irrl- 
tation somewhere in the organism, especially so in nerv- 
ous individuals. Sleeping on the back induces it. The 
causes of nightmare embrace almost all bodily ailments, 
notably digestive disturbances, heart disease, worry and 
excitement. 


TREATMENT OF THE HEART SYMPTOMS. 


PALPITATION oF THE Heart. Absolute rest in bed 
in a large ventilated and darkened chamber with the 
clothing removed. The application of an ice-bag to the 
region of the heart or cloths saturated in cold water 
are very effective agents. Swallowing small pieces of 
ice or drinking large draughts of cold water or a glass 
of hot water, are procedures frequently adopted. To 
prevent attacks of palpitation, excitement of all kinds 


96 THE BLUES :—NEURASTHENIA. 


must be avoided, and tea, coffee, and aleohol must be 
discontinued or at least reduced. When the palpitation 
is dependent on impoverished blood, iron in some form 
is serviceable. When a stomach disturbance is at the 
bottom of the trouble, it must be cured. Electricity is 
an effective agent. It should be given, if possible, twice 
a day in the form of Galvanism; the positive pole on the 
back of the neck and the negative drawn along the course 
of the pneumogastric nerves in the neck. Some cases 
are benefited by residence at high altitudes, others, by a 
sea voyage. Not infrequently the application of cold 
to the spine will arrest a paroxysm. When everything 
else fails, the rest cure often yields good results. 


TREATMENT OF THE STOMACH AND INTESTINAL 
SYMPTOMS. 


Nervous Dysprrsta. In the majority of in- 
stances, indigestion is caused by too rapid eating 
and the consumption of too much food. Digestion 
begins in the mouth. ‘This is especially true of the 
digestion of starchy foods. Many dyspeptics are cured 
of their evil by thoroughly masticating their food. A 
meal should be regarded as a pastime, not a necessity, 
It is difficult and even impossible to lay down any 
definite rule for the kind of food to be consumed, for 
“one man’s food is another man’s poison.” The nery- 
ous dyspeptic is, as a rule, poorly nourished. It is ab- 
surd to suppose that nervous prostration can be cured 
without increasing and making the nourishment effec- 
tive. This statement refers to the qualitative and not 
the quantitative consumption of food. An exhausted 
nervous system demands a plentiful supply of good 
nutritious food. Beard maintains, in his classic work 


THE CAUSE AND CURE. 97 


on “ Sexual neurasthenia,” that flesh is the natural food 
of man. His theory of diet is founded on the theory 
of evolution, and finds expression in the following three 
propositions: 1. Living beings feed on that which is 
below them in the scale of development; 2. The best 
food for man is that which is just below him or nearest 
to him in the seale of development; 3. Food is difficult 
of assimilation for man in proportion to its distance he- 
low him in the seale of development. It is undoubtedly 
true, that those who subsist exclusively upon meat are 
capable of greater mental and physical exertion than 
those who consume vegetable food. Animal food con- 
tains the greatest variety of nutriment and is generally 
most easily digested. Beef is more nutritious and stim- 
ulating than mutton. The flesh of very young animals 
is less nutritious, and more difficult of digestion than 
the flesh of the matured animal. Orysters are very 
nutritious and digestible when consumed raw. Oatmeal 
is a frequent cause of indigestion in the nervous dys- 
peptic. Eggs, milk and fish are very nutritious. When 
the dyspepsia is severe, an exclusive milk diet for sey- 
eral weeks proves curative. The daily amount necessary 
must never be less than three pints, and as much as a 
gallon. <A large glassful should be drunk slowly every 
hour, and, when toleration is established, this amount 
may be increased at shorter intervals. The digestibility 
of the milk may be increased by adding a pinch of salt . 
or a teaspoonful of lime water to each glass. Some pre- 
fer taking the milk diluted with water or seltzer. When 
whole milk is loathsome, it may be skimmed or sub- 
stituted by buttermilk or koumys. Farinaceous foods 
should, as a rule, be excluded, as they create flatulency 
and Beinn: Too much liquid should not be taken at 


98 THE BLUES :—NEURASTHENIA. 


a meal, as it dilutes the gastric Juice and inhibits diges- 
tion. Hygienic measures, such as exercise and bathing, 
are indispensable, for, by increasing the tone of the 
nervous system, they indirectly improve digestion. Suf- 
ferers from nervous dyspepsia will find material aid by 
carrying out the partial rest treatment, and confining 
themselves to the following diet, which excludes starchy 
foods, which are notoriously indigestible in neurasthenic 
persons. 

On waking, eight ounces of equal parts of hot milk 
and seltzer water, taken slowly. Breakfast, steak or 
loin chops with fat, soft-boiled or poached egg, cream 
toast (very little), half a pint of milk and a small eup of 
coffee. Lunch, 10 a. m., small teacup of squeezed beef 
juice with stale bread. 12mM., rest or sleep. Midday 
meal, 12: 30 p. M., fish, chicken, scraped meat ball, stale 
bread with plenty of butter, baked apples and cream, 
two glasses of milk. Lunch, 4 p. m., bottle of koumys, 
raw scraped beef sandwich or goblet of milk. 5:30 
Pp. M., meat or fresh soup, roast or mutton, game, stale 
bread (sparingly), fresh vegetables (excepting pota- 
toes). Eat slowly, chew the food thoroughly, and never 
eat when excited or exhausted. Poorly prepared meals 
are often a source of dyspepsia. Washing the stomach 
by means of a tube is often indicated for the relief of 
dyspepsia. Constipation is frequently a cause of dys- 
pepsia and loss of appetite. 

Personally, I have observed only temporary good to 
result from the use of such agents as pepsin, pancreatin 
and hydrochloric acid. To stimulate digestion, stryeh- 
nin is often invaluable. The addition of common salt 
to our food stimulates digestion. Alcohol should be 


THE CAUSE AND CURE. 99 


stopped, although there can be no objection to a moder- 
ate use of some light wine taken with meals. 
RULES FOR DYSPEPTICS. 

Rute rt Eat slowly and chew the food thoroughly. 
If the foregoing are not observed, then the rule of Sir 
Andrew Clark should be followed, viz.: Count the bites. 
For every mouthful of meat thirty-two bites must be 
allowed, or one bite to every tooth. If the meat is tough, 
sixty-four bites must be allowed, and ninety-six bites, 
if very tough. This rule is an almost positive protec- 
tion against dyspepsia, dependent on hurried eating, 
and will, in most instances, cure the disease. 

Rutz wu. Solids and liquids must be taken at sepa- 
rate times. Liquid taken with food in those with weak 
stomachs dilutes the gastric juice and retards digestion. 
Then again, when liquids are not taken with the food 
it induces the patient to chew the food thoroughly, or 
otherwise it cannot be swallowed. If at breakfast, tea 
or coffee must be drunk, it is better taken at the com- 
pletion of the meal. 

Rove. Farinaceous and proteid foods should not 
be taken at the same meal, in other words, the same 
character of food only should be introduced into the 
stomach at the same meal. For example: Bread and 
butter may be taken at breakfast, but no meat, fish 
or eggs. Luncheon should consist of fish, eggs or meat, 
but no bread, potatoes or other farinaceous food. Sup- | 
per should consist of the same kind of food as at lunch- 
eon, or farinaceous food only. Introducing the same 
kind of food into the stomach at each meal insures the 
completion of digestion at the same time, and not at 
different times, as would be the case, if the character 
of the food taken at a meal is different. 


100 THE BLUES ;—NEURASTHENIA. 


Ruteiv. If liquid must be taken at a meal, the best 
drink is hot water, taken on rising in the morning, at 12 
o’elock, and again at 4 p. m. Taken at these intervals, 
there will be no dilution of the gastric juice, and the 
contents of the previous meal will be washed out of the 
stomach. 

TREATMENT oF ConsTIPATION. Each case of con- 
stipation must be investigated as an individual one. 
Habit is an important factor. The desire to go to stool 
must never be neglected, in fact, it is to be encouraged 
by a systematic habit of going to the toilet every morn- 
ing, whether or not the desire is present. Such a prac- 
tice will often cure the costive habit. Many persons 
find that a cigar or a pipe after breakfast acts as a laxa- 
tive. Massage of the abdomen is constantly practiced, 
but I confess never to have seen any good results from 
its use, save in children and very young persons. Many 
persons succeed in obtaining a daily evacuation by tak- 
ing certain articles of food. Fruit, raw or cooked, 
taken at breakfast, is often effectual. Some find oat- 
meal or brown bread to have a similar effect. 

It is necessary for the patient to secure bowel action 
to have in the intestines a certain bulk of fecal matter. 
The sparing use of vegetables, fruits and water will 
produce a small residue of undigested matter, hence it is 
necessary to partake of food which contains a large 
amount of cellulose, which remaining undigested, fills 
the bowels and provokes vigorous peristalsis. Such 
food consists of vegetables, fruits, coarse breads and 
water. The vegetables that possess laxative properties, 
are: spinach, lettuce, tomatoes, Spanish onions and cab- 
bage. Honey and molasses, taken alone or with other 
food, are frequently laxative. Some people find that 


THE CAUSE AND CURE. 101 


coffee is likewise laxative. Fruit, as a laxative, is most 
efficient when eaten alone, either before retiring or an 
hour before breakfast. Sweet cider is loosening to the 
bowels, whereas tea often constipates. Water should be 
drunk in abundance, especially before retiring or on 
rising in the morning. Others find that a glass of raw 
milk taken before breakfast will act as a laxative. Exer- 
cise is of great value, especially exercise like horse- 
back riding, which brings the abdominal muscles into 
play. The continued use of purgatives is a dangerous 
practice. They are only temporary in action, and make 
the bowels more constipated than ever. The least ob- 
jectionable agents of this class are the natural purgative 
waters, like Carlsbad and Hunyadi Janos. In Cali- 
fornia we possess an effective natural water called 
Bythinia. Suppositories of glycerin or a daily enema 
of cold water is of great value. The same may be said 
of olive oil. Glycerin (a tablespoonful to four table- 
spoonfuls), thrown into the rectum is very effective. 
Cold sponging and baths are valuable additions to the 
measures suggested. 


TREATMENT OF SEXUAL NEURASTHENIA., 


ConsuecaL Hyerenr. Normal sexual intercourse is 
the most powerful passion of human nature, conducive 
‘to strong and vigorous health. When followed by a 
feeling of well-being, it is healthful, but, if, on the con- 
trary, it is followed by depression, the act is harmful. 
Unnatural methods of intercourse, such as withdrawal, 
use of condoms and prolongation of the act, are espe- 
cially harmful, and are often the essential cause of a pro- 
tracted siege of sexual neurasthenia. It must not be 
forgotten that the health of the offspring is largely de- 


102 THE BLUES :—NEURASTHENIA. 


pendent on the condition of the parents at the time of 
the conception, and for this reason, the laws of sexual 
hygiene should be observed most rigorously. Spitzka 
affirms that ‘children begotten by a drunken father 
have repeatedly been found to be epileptic, imbecile, 
deaf, mute or insane.” Undue repetition of the sexual 
act is repugnant to the moral sense, and is certain to 
be followed by evil consequences. Sexual intercourse 
is intended for the purpose of reproduction, and the 
prevention of conception is an injustice to society and 
results in injury to both sexes. 

The treatment of seminal emisstons is generally a 
simple matter, when conducted by the physician. Aside 
from local measures, the building up of the nervous sys- 
tem is an absolute essential. To arrest the emissions 
entirely in a continent unmarried man is an Impossi- 
bility. What can be really achieved is this, to allow 
the emissions to continue without any detriment to 
health. Marriage, while offering immunity in the ma- 
jority of instances, is not invariably productive of such 
results, for there are many married men who continue 
to have emissions. This is, of course, usually unnatural, 
and often indicates that the strength of the organs is 
imperfect, or because no real pleasure is derived from 
the act, or because there still remain traces of former 
sexual troubles. Before emissions can be controlled, 
sexual excitement and masturbation must be avoided. 
The diet should be non-stimulating. Spices, alcoholic 
drinks, strong coffee and tea must not be used. Before 
retiring, very little fluid or food should be taken. Sleep 
should not be prolonged, and early rising is important. 
The patient should never lie on the back, and the cover- 
ing should be ight and the bed hard. When patients 


THE CAUSE AND CURE. 103 


awake in the morning they should at once empty the 
bladder. 

The treatment of sexual neurasthenia in general, 
means the correction of general nerve depression. Aside 
from local treatment, which may be necessary when 
strictures or old discharges complicate the trouble, or 
when a tight prepuce exists or rectal irritation from 
piles or retained fecal matter, the essential object al- 
ways, is the relief of nerve-depression on which the 
sexual disorders are dependent. Charlatans often ag- 
gravate the sexual weakness and irritability by employ- 
ing drugs and different kinds of apparatus, which tem- 
porarily stimulate the debilitated organs, leaving them 
in a worse condition than ever before. In no other 
disease is meddlesome treatment so disastrous as in sex- 
ual debility, and many individuals have been perma- 
nently injured by such measures. There are no specific 
drugs in the treatment of sexual neurasthenia. Even 
moral treatment, so often vaunted by medical writers, 
is of little avail, and while the mind frequently operates 
to the disadvantage of the sexual apparatus, there is no 
affection which is less amenable to moral treatment 
than sexual neurasthenia. Patients see no results in 
expectancy. They want results, and the results which 
they are so eager to obtain can only be achieved by a 
correct toning of the nervous system. 


HYPNOTISM. 


(— Treatment by suggestion, when intelligently em- 
ployed in neurasthenia, is capable of marvelous effects 

in ridding the patient of morbid ideas and in inducing 

sleep, which, even with drugs, is often impossible. 
‘Healthy suggestions made by the physician, I regard 


104 THE BLUES :—NEURASTHENIA. 


as indispensable in the treatment of many cases. The 
dangers of hypnotism are exaggerated, for no one can 
be hypnotized against his wish. Prof. Bernheim, the 
apostle of hypnotism, has this to say: ‘“ It is the duty 
of the physician to select what is useful in suggestion, 
and to apply it for the benefit of his patients. When, in 
the presence of sickness, I think that therapeutic sug- 
gestion has a chance of success, I should consider my- 
self to blame, as a physician, if I did not propose it to 
my patient, and if I did not even make a point of get- 
ting his consent to its employment.”” The influence of 
the mind on the body is every day illustrated by the in- 
troduction of some new fad or delusion in the treatment 
of disease. It is difficult to conceive that such results 
are effected by the mind as a simple thinking organ; 
on the contrary, the mind is psychodynamic, and must 
be regarded as a force like light, heat and electricity 
which operates for good or evil on the bodily functions. 
Strong mental impressions may actuate disease, and 
even death, or they may act by curing disease. Joy 
and hope stimulate, whereas grief and despair depress 
the bodily functions. Sutton presents the following 
facts, which are apposite in this connection: 

Frrst. That mental emotion may induce sickness 
or death within a brief space of time, or even immedi- 
ately, and in persons of robust health. 

Seconp. The physical phenomena induced by such 
cause indicate a deep perturbation—vibration—of the 
nervous system, and are generally of a dynamic char- 
acter. 

Turrp. Thought strongly directed to any part tends 
to increase its vascularity and consequently its sensi- 


bility. 


/ 


THE CAUSE AND CURE. 105 


Fourtu. Thought strongly directed away from any 
part diminishes vascularity and lessens sensibility. The 
more so when associated with powerful emotions. (A 
key which unlocks Christian science and other “ fads.’’) 

Firtu. The emotions may cause sensations, either 
by directly exciting the sensory ganglia and the cen- 
tral extremities of the nerves of sensation, or by in- 
ducing vascular changes in a certain part of the body, 
which excite the sensitive nerves at their peripheral 
termination. | 

Stxtu. There is no sensation, whether general or 
special, excited by agents acting on the body from with- 
out, which cannot be excited also from within by emo- 
tional states affecting the sensory ganglia, such sensation 
being referred by the mind to the point at which the 
nerve terminates in the body. (Tuke.) 

istian Sciénee is suggestion plus absurdity; di- 
vine healing, suggestion plus faith in God; Dowieism, 
suggestion plus prayer and holy terror; Weltmerism, 
suggestion plus imagination, pure; magnetic healing, 
suggestion plus imagination, also; osteopathy, sugges- 
tion plus massage; homeopathy, suggestion plus noth- 
ing; allopathy, suggestion plus tubfuls of drugs that 
either kill or cure; regular or rational medicine, sugges- 
tion plus the best common horse sense available, or sug- 
gestion and medicine mixed with the best quality of 

ains obtainable. No suggestion in this that the quality 
of brains is indisputably good in all cases—or perhaps 
in any. Yet that is the scientific principle at the base, 
and it may be used with telling effect in all cases of 
sickness, and is infinitely better than the delusions of 
the day by so much as it substitutes intelligence for ig- 
norance and does not produce that disaggregation of 


106 THE BLUES :—NEURASTHENIA. 


personal consciousness and temporary insanity that is 
the sine qua non in Christian Science, ete. 
here are many competent writers who doubt the 


eee of hypnotism in therapeutics and aver that its. 


i 


oe merenoreremn gene" 


i 


0 Ra 


results are achieved at the expense of demoralization. 
My own observations with hypnotism as a therapeutic 
agent extending over a period of fifteen years justify 
me in the conelusion, that when judiciously employed 
i carefully selected cases, it is a most effective agent, 
‘and results may be a eahed which are ines nae i 
achievement by any other known means. The latter 
“Statement refers not only to disease, but also of educa- 
tion for the improvement of eae and morals. It 


“was supposed at one time that only weak, sick, nervous 


and hysterical women were susceptible to hypnotism, 
but the extensive statistics of Liébault have shown that 
almost anybody can be hypnotized, the susceptibility to 
suggestion being influenced by willingness of the sub- 
ject, his passivity and the power to concentrate the 
thought or attention on the intended sleep. Intelligent 
persons are more difficult subjects than mechanics or 
laborers, because they permit their thoughts, whether 
voluntary or involuntary, to wander to various objects 
which distract the attention. Patience and renewed 
seances are often rewarded by suecess in those who are 
not susceptible to the influence. Young are more sus- 
ceptible than old persons, and women more easily in- 
fluenced than men. 


THE CAUSE AND CURE. 107 


SUMMARY. 


1. Reliance on the healing power of Nature is an 
evidence of erudition. It affords the discerning physi- 
cian an opportunity of knowing what not to do, a feat 
often more difficult than doing, and enables him to 
~ apply the highest principles of the therapeutic art. 

2. ‘* The confession and absolution of sanitary sins 
is a constant physical force in medical practice. The 
physician is the priest of health; his gospel is the one 
of right living.” (Dr. H. C. Sawyer.) 

3. “The attitude of a patient should be that of 
a voyager who resigns himself to the captain, and does 
not look for the further shore until the time comes.” 
(Beard. ) 

4. “There is wisdom in this beyond the rules of 
physie. A man’s own observation, what he finds good 
and of what he finds hurt of, is the best physice to pre- 
serve health.” (Bacon. ) 

5. ‘We are all prone to forget—that we are deal- 
ing with human beings whose hopes and fears are played 
upon by our every word and act as subtly as the most 
wonderful musical instrument is touched by the fingers 
of the master performer. We may thus be the creators 
of the sweetest strains of human feeling, or the insensi- 
ble performers upon sweet bells jangled out of tune.” 
(Dr. Geo. M. Gould.) 

6. ‘A physician whose horizon is bounded by an 
historical knowledge of the human machine, and who 
ean only distinguish terminologically and loeally, the 
coarser wheels of this piece of intellectual clock-work, 
may perhaps be idolized by the mob, but he will never 


108 THE BLUES :—NEURASTHENIA. 


raise the Hippocratic art above the narrow sphere of a 
mere bread-earning craft.” (Schiller. ) 

7. “Any physician who neglects to approach phys- 
ical symptoms through the mind will find the practice 
of medicine a sorry task. The physician is often com- 
pelled to conciliate the mind of the patient while Na- 
ture is effecting the cure. 

8 “To eat little, and that little of simple food, is 
to prolong life.” (Cornaro. ) 

9. ‘For my part, when I see a fashionable table set 
out in all its magnificence, I fancy I see gouts and drop- 
sies, fears and innumerable distempers lying in ambus- 
cade among the dishes.” (Addison. ) 

10. ‘Good ventilation and a certain amount of out- 
of-door bodily exercise are of the greatest importance 
and greatest necessity in insuring good, refreshing sleep, 
as well as a good old age.” (Hufeland.) 

11. “ Those are greatly mistaken who believe that a 
modern physician is he who examines a patient most 
carefully, auscultates and percusses, and is satisfied when 
the autopsy corresponds with his diagnosis. Such a 
medical man does not comprehend that the aim of all 
medical service is the healing of the sick.” (Oppolzer.) 

12. “Pathology is the physiology of the sick.” 
(Wunderlich. ) 

13. ‘ Let me diet a person and I can give him al- 
most any kind of disease known,—long life or short 
hfe.” (Dr. T. R. Allison.) 

14. ‘ Medicine has taken possession of hypnotism, 
and it is only through her that such an agent can be 
made of use to mankind and prevented from working 
injury to the human race.” (Charcot.) 


THE CAUSE AND CURE. 109 


15. Decalogue of Health (Dr. Frank H. Hamil- 
ton): 

“1. The best thing for the inside of a man is the 
outside of a horse.”’ 

“9, Blessed is he who invented sleep—but thrice 
blessed the man who will invent a cure for thinking. 

“3. Light gives a bronzed or tan color to the skin; 
but where it uproots the lily it plants the rose. 

“4. The lives of most men are in their own hands, 
and, as a rule, the just verdict after death would be— 
felo de se. 

“5. Health must be earned—it can seldom be 
bought. 

“6. A change of air is less valuable than a change 
of scene. The air is changed every time the wind is 
changed. 

“7. Mold and decaying vegetables in a cellar weave 
shrouds for the upper chambers. 

“8. Dirt, debauchery, disease, and death are suc- 
cessive links in the same chain. 

“9. Calisthenics may be very genteel, and romping 
very ungenteel, but one is the shadow, the other the sub- 
stance, of healthful exercise. 

“10. Girls need health as much—nay, more than 
boys. They can only obtain it as boys do, by running, 
tumbling—by all sorts of innocent vagrancy. At least 
once a day girls should have their halters taken off, the 
bars let down, and be turned loose like young colts. 

“11. The alimentary regimen in neurasthenia is im- 
portant, for neurasthenics eat too much. The amount of 
food consumed should be reduced to what is absolutely 
necessary and this is gauged by weight and strength. 
Tf the latter, grow less, the amount of food taken must 


110 THE BLUES :—NEURASTHENIA. 


be increased. Neurasthenics eat too much, but do not 
drink enough. At least 3 pints of water should be ad- 
vised for daily consumption. Digestion always means 
an expenditure of nerve force, therefore it is wise to 
remember that a minimum of food means a minimum of 
digestive work. The foregoing facts are specially ap- 
plicable in splanchnic neurasthenia. 

“12. I believe it was Carlyle, who said ‘ that the 
average American meal was an unpunished crime.’ 
Nervous dyspepties should not indulge in regulation 
meals, but should eat often. This rule, if followed, will 
reduce the task of a stomach suddenly overburdened with 
food and will diminish the tendency to overeat. 

“13. The recent experiments of Prof. Anderson, of 
Yale University, prove that the most important thing’ 
in all exercises is the mental effort put forth. Exercises 
if conducted automatically, will not divert the blood as 
they should from the brain to the muscles. Prof. Gates, 
was able, by thinking intently of one of his hands, when 
it was immersed in a basin full of water, and willing 
that the blood should flow there, to make the water over- 
flow. The foregoing facts are sold by teachers of physi- 
cal culture for good prices and they emphasize that very 
little exercise, with the mind directing it, will effectually 


rebuild the body.” 


CHAPTER VI. 


SPLANCHNIC NEURASTHENIA. 


THE BLUES. 


WHY THE TERM, “ THE BLUES,’ HAS BEEN EMPLOYED TO 
SPECIFY THIS PARTICULAR FORM OF NEURASTHENIA. 
—DATA BEARING ON SPLANCHNIC NEURASTHENIA.— 
INTRA-ABDOMINAL PRESSURE, PULMONARY SUCTION, 
VASOMOTOR FACTOR.—THE ABDOMINAL SYMPATHETIC. 
—FACTORS CONTRIBUTING TO SPLANCHNIC NEURAS- 
THENIA. 





SpLaNcHNic NEURASTHENIA is, above all things, 
characterized by attacks of depression, which come on 
spontaneously without apparent cause and depart as 
mysteriously as they came. The subjects of such at- 
tacks specify their condition at the time as “a fit of the 
blues.” “ The blues,” occur usually in neurasthenic in- 
dividuals, and, being of short duration, in most in- 
stances, may be spoken of technically as attacks of acute 
neurasthenia. Not infrequently, they may be of pro- 
longed duration, in which instances, they may be re- 
ferred to as exacerbations of chronic neurasthenia. To 
clearly comprehend splanchnic neurasthenia, it will be 
necessary to direct our attention to the abdomen and re- 
strict consideration to intra-abdominal tenston and the 
effects of such tension on the blood circulation in the 
abdomen. 


lil 


112 THE BLUES :—NEURASTHENIA. 


Inrra-ABpominaL Trnston. This refers to the 
pressure in the abdominal cavity. In the normal sub- 
ject, the pressure is positive, that is, it is greater than 
the atmospheric pressure, hence the abdominal walls are 
pressed outward. Tension within the abdomen is chiefly 
dependent on the contraction of the abdominal walls, and 
this in turn is dependent on the strength of the muscles 
which make up the abdominal walls. In other words, 
when the abdominal muscles are strong, all other things 
being equal, intra-abdominal tension is increased, and 
when they are feeble, the same tension is decreased. . 


FACTORS WHICH INCREASE AND DECREASE 
INTRA-ABDOMINAL PRESSURE. 


The tone of the anterior abdominal muscles is in- 
creased in certain occupations which tend to develop 
them. Thus, the strong, hard, flat abdomens of fisher- 
men who fish with nets and spend many hours dragging 
at the ropes may be contrasted with the protruding 
bellies of shoemakers and tailors, in whom an insufficient 
development of the muscles occurs, owing to their relaxa- 
tion, the result of posture in their special occupations. 
Tension is diminished, when fat accumulates in the walls 
of the abdomen, in corset-wearing women and chiefly as 
a result of pregnancy. Schwerdt,?? refers to reduced 
intra-abdominal pressure as a result of relaxation of the 
whole nervous system, which reacts on the muscular 
system. Other factors concerned in the reduction of ten- 
sion are: 1. Hereditary factors; 2. Mental overwork; 
3. Insufficient nourishment; 4. Chronic diseases. <Ac- 
cording to Glenard,”? diminution of the intra-abdominal 
tension is due more to the lessening of the volume of 
gas in the intestines than to any other cause. That this 


THE CAUSE AND CURE. 113 


latter cause is important, I will endeavor to show later, 
but I do not accept the view of Glenard, viz.: that intra- 


‘abdominal tension is the expression of the forces which 


regulate the relationship between the capacity of the 
abdominal cavity and the volume of its contents. When 
the abdominal walls atrophy, the intestines fill with 
gas. 

Errects oF Druinispep [yrra-AspominaL TEN- 
ston. The positive pressure exerted by the tonic con- 
traction of the anterior abdominal muscles is probably 
the most important factor in keeping the abdominal. 
organs in place, for when they are relaxed as a perma- 
nent condition, their pressure on the underlying struc- 
tures is insufficient and the result is, a dislocation of 
the organs. This particular function of abdominal ten- 
sion, while an important one, merits little consideration 
in developing our particular subject, viz.: splanchnic 
neurasthenia. While it is true, that dislocation of the 
abdominal organs is associated with a very intractable 
form of neurasthenia, with preponderance of abdominal 
symptoms; in splanchnic neurasthenia, dislocation of the 
abdominal organs has been an infrequent phenomenon 
in my experience, and when present, was only indirectly 
concerned in the nervous symptoms. In fact, in disloca- 
tion of the abdominal organs, the development of subse- 
quent nervous symptoms is due largely to the effects on 


the abdominal circulation, and this, together with ptosis 


of the viscera, is only an effect of diminished intra- 
abdominal tension. 

Errects or Repucep Intrra-AspomiInaLt TENsIon 
ON THE CrrouLaTION. This is the most important fac- 
tor concerned in splanchnic neurasthenia, and has re- 
ceived scant consideration from physicians, a most la- 


8 


Yee: 


114 THE BLUES :—NEURASTHENIA. 


mentable fact, considering the gravity of the issues in- 
volved. Tension within the abdominal cavity directly 
influences the blood circulation in the abdominal organs, 
digestive functions and indirectly almost every organ of 
the body. The abdominal veins are very capacious, and 
experiments have taught, that they are capable of hold- 
ing all the blood in the body. The amount of blood in 
the abdominal or splanchnic veins is merely a question 
of abdominal tension. When the latter is diminished, 
the veins contain more blood than when the tension is 
increased. Hull and Barnard,?* have contributed largely 
to this important subject in a physiologic direction, and 
Campbell,”° has sought to elaborate it practically. They 
have demonstrated that there is a tendency of the blood 
to accumulate in the splanchnic area, with consequent 
syncope. Like the generality of veins, the great splanch- 
nic veins are very susceptible to pressure, and the 
amount of blood within them is greatly influenced by 
pressure of the abdominal walls. Mere pressure of the 
abdomen suffices to squeeze out of the veins a large quan- 
tity of blood. Thus gravity, posture, the accoutrements 
of dress and other factors greatly influence the amount 
of blood contained in the abdominal veins. More blood 
accumulates in the veins in the erect than in the recum- 
bent posture, and it is not an uncommon observation 
for syncope to occur in bedridden patients, who are 
suddenly constrained to get out of bed. The removal 
of stays in women often induces a feeling of faintness, 
and the same symptom may occur in susceptible persons 
when the bladder is voided or the feces discharged. 
Three factors enter into consideration in the mechanism 
of blood supply to the splanchnic vessels, viz.: 1. The 
contraction of the abdominal muscles; 2. The act of 


THE CAUSE AND CURE. 115 


respiration; 3. The regulating vasomotor action of the 
splanchnic vessels. 

Tur Aspominat Factor. The transversales mus- 
cles maintain the anterior posterior abdominal walls in 
fairly close contact, and prevent, in the erect posture, 
gravitation of the blood into the splanchnic veins. 

Tue Resprratory Factor. That important muscle 
of respiration, the diaphragm, acts in opposition to the 
abdominal muscles. Weakness of the abdominal muscles 
signifies a weak diaphragm. When the latter contracts, 
it has to work against the intra-abdominal pressure, 
which it increases, hence, if abdominal pressure is re- 
duced by weakened abdominal muscles, the diaphragm 
has little work to perform and consequently its strength 
diminishes. Every time the diaphragm descends, the 
intra-abdominal vessels are compressed, and the action 
thus exerted is less evident in the tense arteries than in 
the flaccid veins; the blood being squeezed out of the 
latter into the right chambers of the heart. De Jager °° 
has shown, that even strong pressure upon the abdomen 
has little or no effect on the arteries, but serves to squeeze 
a large quantity of blood from the splanchnic veins. 
Hill has also shown that, in consequence of some failure, 
in certain compensatory mechanisms, the blood gravi- 
tates into the splanchnic veins from the right heart and 
that pressure upon the abdomen will send back the blood 
from these veins to the right heart, and thus re-establish 
the circulation. 

Putmonary Suction refers to the large quantity of 
blood drawn into the lungs with each inspiration, and 
this physiologic process has not been inaptly compared 
to a species of dry cupping. Chapman?" avers, ‘ That 
if at the termination of expiration the quantity of blood 


¢ 


116 THE BLUES :—NEURASTHENIA. 


in the lungs is from 1-15 to 1-18 of the total quantity of 
blood in the body, at the termination of inspiration, it 
will be from 1-12 to 1-13.” The pulmonary vessels ex- 
pand with each inspiration and contract during expira- 
tion, the result being an increased flow of blood from 
the right heart and the lungs; the dilated vessels, as 
Campbell 28 puts it, “actually suck the blood out of 
the right heart.” 

Vasomotor Factor. The splanchnic nerves possess 
the power of regulating the amount of blood in the 
splanchnic veins, and prevent the gravitation of blood 
into them. 

The quantity of blood, which may be foreed by ab- 
dominal pressure into the heart, and from thence into 
the general circulation, has never been determined ob- 
jectively until I directed attention to what I have called 
the “ Cardio-Splanchnic Phenomenon.” * It was this 
phenomenon which enabled me to appreciate the ten- 
dency of blood to gravitate into the abdominal veins in 
many neurasthenies, and to inhibit the symptoms of the 
latter by treatment directed against this tendency. Be- 
fore elaborating the phenomena which contribute to this 
special form of neurasthenia, I wish briefly to direct 
attention to the nerve apparatus, which presides over 
the function of innervation of the organs contained in 
the abdominal cavity, viz.: the abdominal sympathetic. 

Tue AppomrnaL Symparuetic. The relations of 
the great sympathetic with the cerebro-spinal axis, and 
the nature of its functions is a matter involved in much 
obscurity. This much we do know, however, that it 
exerts an important influence over the circulation, secre- 
tions and nutrition of the organs innervated by it. In 


* See Appendix, Note 2. 


THE CAUSE AND CURE. ibe 


health, the abdominal sympathetic confers an uncon- 
scious sensibility to the abdominal organs, but when irri- 
tated from any cause, violent pains and abnormal sensa- 
tions are experienced, not only at the point of irrita- 
tion, but reflexly, owing to its communication with 
branches of the cerebro-spinal system of nerves, at re- 
mote situations. Irritation of the splanchnic nerves is 
attended primarily by contraction of the abdominal 
vessels, but the latter soon dilate, leading to a stagna- 
tion of blood. Byron Robinson ?® refers to the celiac 
ganglia, the largest in the body, as the ABpomMiInaAL 
Brain, which acts as a reflex center outside of the 
spinal cord. 

Meinert *° claims that the celiac plexus controls the 
formation of hemoglobin in the spleen. The coats of all 
the principal blood-vessels in the abdomen are supplied 
by the sympathetic nerve, which regulates the vascular 
supply to the organs. 


FACTORS WHICH CONTRIBUTE TO THE DEVELOP- 
MENT OF SPLANCHNIC NEURASTHENIA. 


This form of neurasthenia is dependent essentially on 
a stagnation of the blood in the splanchnic or abdominal 
veins. This is the primary and fundamental condition 
prevailing in splanchnic neurasthenia. The factors 
which conduce to this condition are many, but in most 
instances, it is lack of nerve force exerted through the 
muscles of the abdomen and respiration and the nervous 
mechanism which regulates the supply of blood in the 
veins. From this, one would be constrained to conclude, 
that the phenomenon of blood stagnation in the abdom- 
inal veins is not a primary but a condition secondary 
to neryous exhaustion. In this contention, one would be 


118 THE BLUES :—NEURASTHENIA. 


partially correct, for, while it is usually a secondary 
eondition, it is not infrequently a primary one. It is 
eapable of aggravating a neurasthenie disposition, and 
induces it when absent. By treatment directed toward 
the stagnation of blood in the abdominal veins, I have 
succeeded in curing many neurasthenics of their vicious 
symptoms, notably, mental depression and of limiting 
their fatigue signs to the sphere to which they properly 
belong, the brain and spinal cord. This is practically 
all that can be accomplished for the neurasthenie by the 
physician. The fatigue symptoms of the former are 
the result of his own indiscretion, and his mastery of 
them presumes sufficient intelligence, which enables 
him to recognize his own power of endurance. 

Nerve Force Lacxine In THE MUSCLES OF THE 
AspoMEN. JI have already shown that the greater in- 
tra-abdominal tension, the less blood will be contained 
in the abdominal veins. Furthermore, that this tension 
is largely dependent on the tone or tension of the 
abdominal muscles. Now, tone in any muscle or group 
of muscles is the product of a storm of nervous impulses 
pouring into them from a nerve center, and when the 
latter is fatigued, the tone of the muscle diminishes, 
which is expressed by relaxation of the muscular fibers. 
Therefore, nervous exhaustion is a frequent cause of 
diminished tone of the abdominal muscles, which in 
turn diminishes intra-abdominal tension, and conduces 
to blood stagnation in the veins of the abdomen. 

Nerve Force Lackine 1n tur Function or Resptr- 
RATION. Here, as in the preceding condition, the same 
cause prevails. Not only in neurasthenia, but in other 
functional nervous diseases, respiratory exercises have 
been shown to be of great value. This effect, to my 


THE CAUSE AND CURE. 19 


mind, has been achieved through their influence on the 
abdominal circulation. The lungs are important ave- 
nues for the elimination of poisonous substances, many 
of which are scarcely known. By healthy lung action, 
we may regulate the local and general blood and lymph 
circulations. Such effects are not only local, but gen- 
eral, for every protoplasmic unit of the body to live 
must have its essential quantity of oxygen, and receiving 
this, yields in return its products of activity. We have 
already referred to “ pulmonary suction,” showing how, 
with each inspiration, the blood is sucked, as it -were, 
from the veins throughout the body, and this, in refer- 
ence to the abdominal veins constitutes an important 
factor in diminishing venous turgescence in the abdom- 
inal cavity. The flow of blood is urged primarily into 
the cave and right heart, from the latter into the lungs, 
and from the latter into the left heart. In other words, 
depletion of the veins is accomplished by forcible res- 
piration, so that the supply to the arteries is thereby 
increased, and nutrition of the tissues and organs facili- 
tated. The question of blood pressure, as a result of 
compression of the abdomen, is referred to in the ap- 
pendix.* There is another factor concerned in respira- 
tion, which bears on the venous circulation in the ab- 
dominal cavity, and that is, the descent of the dia- 
phragm. very time the latter muscle descends in in- 
spiration, it increases intra-abdominal tension, and ex- 
presses a considerable amount of blood out of the intra- 
abdominal veins into the right heart. The action of 
the diaphragm in effecting this object is dependent on 
the condition of the abdominal walls: if they are vig- 
orous, intra-abdominal tension is increased, and the 


* See Appendix, Note 3, 


120 THE BLUES :—NEURASTHENIA. 


quantity of blood squeezed out of the veins is correspond- 
ingly augmented; if the abdominal walls are relaxed, 
there is little or no effect on the intra-abdominal tension, 
nor on the intra-abdominal veins. 

Nerve Force Lacxrne in THE Nervous Mecuan- 
ISM WHICH REGULATES THE SUPPLY OF BLoop IN THE 
AspomiInaL Vetns. The vasomotor nervous system 
supplies the muscular tissue in the walls of the blood- 
vessels and regulates their caliber. Ordinarily, the 
small arteries are maintained in a state of moderate or 
tonic. contraction, which is necessary to force the blood 
in a continuous stream through the capillaries and veins 
back to the heart. Another function exercised by this 
system is to regulate the amount of blood which flows 
through the capillaries of any organ in proportion to its 
needs. Thus, during digestion, it is imperative that 
there should be a large quantity of blood supplied to the 
digestive organs, hence at this time, the small arteries 
of the splanchnic area are relaxed, and there is a large 
amount of blood in this area, and a corresponding small 
amount in other areas, such as the skin, and it is for 
this reason that sensations of chilliness are experienced 
after a capacious meal. Splanchnic neurasthenies for 
a similar reason experience an intensification of their 
symptoms after a full meal, for it is at this time that 
the abdominal organs are surcharged with blood. The 
most important vasomotor nerves of the body are the | 
splanchnics, with their cell stations situated in the 
various ganglia of the abdominal plexuses. Now, in 
many cases of neurasthenia (Angiopathic neurasthenia) 
the vasomotor symptoms are extremely prominent, and 
it would seem as if the nerve exhaustion in such cases 
were mainly resident in the vasomotor system. 


THE CAUSE AND CURE. E1941 


RecaPiruLation. Reviewing the factors concerned 
in splanchnic neurasthenia, we may deduce the follow- 
ing: Defective innervation from any cause leads to con- 
gestion of the abdominal veins; Venous congestion in- 
terferes with a proper supply of arterial blood; The 
tissues and organs bathed in pools of stagnant blood are 
practically in a state of asphyxia; The toxic products of 
digestion, which are normally removed by an unim- 
peded circulation, have a specifically poisonous effect 
on the sympathetic system, a fact which is evident, owing 
to the frequent occurrence of depression, prostration and 
nervous symptoms in nearly all disorders of the ali- 
mentary canal. Venous congestion diminishes the vital 
tone of the organs and lessens their vital resistance. 
This subject will be further elaborated in the next chap- 
ter on the symptoms of splanchnic neurasthenia. 


122 THE BLUES :—NEURASTHENIA., 


SUMMARY. 


1. Depression is one of the most important symp- 
toms of splanchnic neurasthenia, hence the layman 
is prone to specify his sensations as a “‘ fit of the blues.” 

2. “A fit of the blues” is, technically speaking, 
acute neurasthenia, but it may also be an aggravated 
paroxysm of chronic neurasthenia. 

3. The entire question of splanchnic neurasthenia is 
one of abdominal plethora, dependent on a variety of 
causes, notably, diminished intra-abdominal tension, in- 
sufficient lung development, and a defective vasomotor 
apparatus. 

4. The foregoing causes are dependent in a great 
measure on diminished nerve tone, which seeks the fore- 
going avenues for expression. 

5. Splanchnie neurasthenia is one of the few forms 
of neurasthenia amenable to permanent cure by meas- 
ures having for their object the relief of abdominal 
venous congestion. 

6. Intra-abdominal venous congestion is tantamount 
to asphyxiation of the abdominal viscera with all its evil 
consequences, 


CHAPTER VII. 
THE SYMPTOMS OF SPLANCHNIC NEURASTHENIA. 


HISTORY OF A SPLANCHNIC NEURASTHENIC.——ANALYSIS 
OF THE MOST PROMINENT SYMPTOMS.——RELAXED AB- 
DOMINAL WALLS, PROTRUSION OF THE ABDOMEN.— 
GAS ACCUMULATION IN THE BOWELS, INCREASED AB- 
DOMINAL TENDERNESS, ENLARGEMENT OF THE LIVER, 
AND INSUFFICIENT LUNG DEVELOPMENT. 


I witt introduce this subject by presenting, in detail, 
the history of a patient, the subject of splanchnic new 
rasthenia, after which, I will submit to analysis the 
most prominent symptoms. 

History or A Casr or SpLancunic NEURASTHENIA. 
The patient is an attorney, age 35. He presents no defi- 
nite history of excesses of any kind. For the past three 
years he has become exceedingly irritable, and has what 
he calls “ blue streaks,” which come on at irregular in- 
tervals without any apparent cause, although he is in- 
clined to the behef that he can nearly always trace their 
origin to some error in diet. What this error is, he does 
not know; it is not any particular kind of food, but it 
may be a late supper or a meal eaten hastily. At any 
rate, during his “blue streaks,” he has uncomfortable 
abdominal sensations, which he is unable to describe 
fully. Although his bowels move regularly during his 
“blue periods,” they are inclined to looseness. His 


123 


124 THE BLUES :—NEURASTHENIA. 


“blue streaks ” have become more frequent of late, and 
last longer. Intense mental depression and prostration 
attend the attacks. At such times he is incapable of 
doing work. He wants to be left severely alone during 
the attacks. Of late, his memory has become affected, 
and he is unable to concentrate his attention. He lacks 
decision in his mental operations and control. He has 
morbid fancies. He thinks that death would be a happy 
release from his suffering, and constantly dwells on the 
subject of self-destruction. In the intervals of his at- 
tacks, which have become less and less frequent, he never 
has the sensation of well-being. He can no longer pur- 
sue his vocation with the same buoyancy as before, in 
fact, he works automatically. His symptoms are inten- 
sified after eating, and for an hour or so, after a meal, 
he becomes horribly depressed and irritable. He has 
no symptoms of indigestion in the ordinary sense, but 
large quantities of gas accumulate in the bowels. For a 
time, he practically starved himself, so that he could 
be released from the depression and irritability follow- 
ing meals. He has submitted himself to all kinds of 
treatment without relief. One physician had treated 
him for urie acid neurasthenia, and at that time he ex- 
perienced tempoyary relief. My examination revealed 
in brief the following: Imperfect lung development, 
feeble heart action, protrusion of the abdomen with gas 
accumulation in the bowels, exquisite sensitiveness of the 
abdomen, enlargement of the liver, which was extremely 
painful on pressure, and the abdominal walls were re- 
laxed and showed no tone. Removal of the stomach 
contents after a test meal demonstrated no anomaly. 

This is in brief, the typical history of a case of 
splanchnic neurasthenia. 


THE CAUSE AND CURE, | 125 


The objective signs will primarily merit our consider- 
ation. 

Tue Aspomrnat Watts. Relaxation of the abdom- 
inal walls is a common objective sign in this form of 
neurasthenia. The abdomen is normally flat, and re- 
mains so in health until the end of life. In some, 
especially women, a hanging belly is best observed when 
the patient assumes the erect posture. In the horizontal 
position, the abdomen flattens and bulges at the sides. 
The skin of the abdomen is loose, and this, together with 
the flaccid walls, allows not only easy palpitation of the 
underlying organs, but they may sometimes be seen. 
Feeble abdominal muscles may be concealed by a large 
deposit of fat, but the condition of the muscles may be 
fairly gauged by directing the patient to raise the body 
while lying supine or to bear down forcibly, when the 
vigor of muscular contraction can be estimated by the 
fingers. In pronounced cases, there is a wide space be- 
tween the abdominal recti. Another method of testing 
relaxed abdominal walls is to stand behind the patient, 
place the hands at each side of the abdomen and then, 
drawing the abdomen wall toward you, suddenly release 
it; the degree of relaxation is determined by the dis- 
tance which the abdominal wall falls after its release. 
Stiller ** referred to a sign which was present in a large 
number of neurasthenics, specially those who were lean 
and dyspeptic, and that was, a mobile tenth rib, which 
was not fixed with the cartilage to the other ribs, but was 
either wholly free (or floating) or attached only with 
hgament. This “ Costa fluctuans decima” is, accord- 
ing to him, very common in delicate children and that 
they are apt to become neurasthenics or enteroptotics 


126 THE BLUES :—NEURASTHENIA. 


later in life, according as nervous or dyspeptic symp- 
toms predominate. 

Our main object in testing relaxation of the abdom- 
inal wall in splanchnic neurasthenia is really to. deter- 
mine how far such relaxation comprises the intra-ab- 
dominal venous cireulation, and for this purpose 
reference is made to the cardio-splanchnic phenomenon.* 
The more the latter is in evidence, as determined by the 
degree of dulness and the extent of its area, the more 
pronounced will be the circulatory embarrassment. 

PROTRUSION OF THE ABDOMEN. This occurs, as a 
rule, owing to diminished intra-abdominal pressure on 
the intestines, which allows their readier distension with 
gas with consequent pressure effects on the abdominal 
wall. 

Gas AccUMULATION IN THE Bowrts. This is a fre- 
quent symptom, and, which I hope to show, is one 
of compensation. The accumulation of gas in the intes- 
tines increases intra-abdominal tension, and any increase 
in the latter means diminished intra-abdominal venous 
congestion. ‘The gases of the intestinal canal are de- 
rived in part from the air (oxygen and nitrogen), in 
part from the ingesta (carbonic acid) and in part from 
intestinal fermentation (ammonia, carbonic acid, hydro- 
gen, hydrogen sulphide, ete.). Some of the gas is re- 
moved by eructations and by flatus, as well as through 
resorption by the blood-vessels, as is evidenced by the in- 
creased excretion of carbonic acid through the lungs, oc- 
curring usually about an hour after a meal. In the chem- 
istry of respiration, the air in the lungs and the blood in 
the capillaries are separated only by the thin capillaries 
and alveolar walls. The blood parts with its excess of 


* Appendix, Note 2. 


THE CAUSE AND CURE. 127 


carbonic acid to the air in the lungs, and the blood simul- 
taneously engages the oxygen from the air in the lungs. 
This intake of oxygen and output of carbonic acid takes 
place all over the body, and constitutes what is called 
tissue-respiration. If we apply this theory to the con- 
gested abdominal veins, we have the following: The 
intestines and abdominal veins represent two chambers 
containing a mixture of gases in unequal amount; dif- 
fusion takes place until the percentage amount of each 
gas in each chamber is the same. Owing to the stagna- 
tion of blood in the abdominal veins, the latter contain 
a large quantity of carbonic acid, hence carbonic acid dif- 
fuses from the veins to the intestines. The intestines now 
being inflated, increase intra-abdominal tension, which 
in turn squeezes the blood out of the abdominal veins 
to the right heart. After this manner, gas accumula- 
tion in the intestines, is, as I view it, distinctly a com- 
pensatory process, and the results attained by treatment 
justify this conclusion. Gas accumulation in the intes- 
tines in splanchnic neurasthenia gives rise to many 
symptoms, especially referable to the heart.* 


INCREASED SENSITIVENESS OF THE ABDOMEN.* 


Splanchnic neurasthenies, as a rule, are very suscep- 
tible to pressure made on the anterior abdominal wall. 
The abdomen may be diffusely sensitive on deep pressure 
or the sensitive points may be localized, and remind 
one of the hysterogenic zones. The site of predilection 
of the sensitive points is the lower abdomen. Not infre- 
quently pains radiate to the back, to the neck and to the 
legs, and may be of the most agonizing character. The 


* Appendix, Note 4. 
* Appendix, Note 11. 


128 THE BLUES :—NEURASTHENIA. 


pains in question do not admit of localization with ref- 
erence to any nerve trunk, or its terminal distribution, 
and they are not modified by pressure, rest nor move- 
ment. These facts suggest the abdominal origin of the 
pains which dre probably caused by congestion of the 
intra-abdominal veins irritating the terminal ramifica- 
tions of the splanchnic nerves. There is one fact worthy 
of mention in diagnosis with reference to abdominal 
sensitiveness and liver tenderness, and that is, if firm 
compression of the abdomen is made with the hands and 
the process repeated for several minutes, abdominal sen- 
sitiveness, liver tenderness and the radiating pains be- 
come markedly abated and even disappear after several 
minutes. The phenomenon in question is clearly the 
result of the maneuver, and receives the following expla- 
nation: Abdominal compression will squeeze the blood 
out of the intra-abdominal veins, and will thus remove 
the source of irritation acting on the splanchnic nerves. 

ENLARGEMENT oF THE Liver.* This is an almost 
invariable accompaniment of splanchnic neurasthenia. 
Aside from enlargement, the liver is always palpable, 
and found to be exquisitely painful. It is more painful 
after eating, and the sensation of fullness experienced 
after a meal by splanchnic neurasthenics is frequently 
caused by hepatic engorgement. This hepatic tender- 
ness 1s always associated with neurasthenie symptoms, 
and is always more pronounced when the latter are in- 
tensified. After a night’s rest, the hepatic tenderness 
is no longer evident in the morning, but soon after break- 
fast it reappears and becomes more marked as the day 
proceeds, increasing in severity after each meal. He- 
patic enlargement and tenderness may be made to dis- 


* Appendix: Note 5. 


THE CAUSE AND CURE. 129 


appear in most instances by vigorous massage of the ab- 
domen and the application of the sinusoidal current, 
facts which will be elaborated in the chapter on the 
special treatment of splanchnic neurasthenia. The sin- 
usoidal current induces what I have ealled the liver 
reflex.* The liver has from time immemorial been sur- 
reptitiously accused of participation in an attack of “ the 
blues,” and, for want of a better term, “ biliousness ” 
has heretofore been employed to designate the condition. 
I have frequently examined individuals during an at- 
tack of “ the blues,” and have established the fact to my 
own satisfaction that hepatic enlargement and tender- 
ness accompany the paroxysm. Furthermore, that treat- 
ment having for its object the depletion of the intra- 
abdominal veins will abort an attack or diminish its 
severity. In what way does the liver participate in the 
attacks in question? The amount of blood which the 
liver contains has been estimated by Foster * to be 
equivalent to one-fourth the amount of blood contained 
in the body. The blood is chiefly derived from the portal 
vein, which collects blood from the stomach, intestine, 
spleen and pancreas. Digestion increases the amount 
of blood contained in the intra-abdominal veins (physio- 
logic congestion), a fact which accounts for the drowsi- 
ness felt by some dyspepties soon after eating, the result 
of brain anemia from portal congestion. The cold ex- 
tremities of some dyspeptics during the digestive stage 
admit of the same explanation. 

My investigations show that coincident with this con- 
gestion of the intra-abdominal veins after meals there is 
a corresponding rise in the blood pressure which is most 
pronounced one hour after meals, then it gradually falls 

* Appendix: Note 6. 

9 


130 THE BLUES :—NEURASTHENIA. 


until the next meal time. It is this increased blood 
pressure after meals which aggravates the condition of 
the splanchnic neurasthenic at such particular periods, 
the augmented blood pressure injuring the delicate tis- 
sues of the brain by a series of powerful uniform blows, 
and one is justified in referring to such action as, the 
traumatism of high blood pressure. 

Now, the secretion of the bile is effected by stimula- 
tion of the liver cell by digestive products carried to the 
liver. Aside from the many established functions of the 
liver, experiment and pathology demonstrate that the 
liver is endowed with the function of not only arresting 
but of destroying toxic substances which are developed 
in the ordinary process of digestion and from intestinal 
putrefaction. It is not difficult to understand, then, why 
it is, that in splanchnic neurasthenia, hepatic tenderness 
and enlargement are worse after eating, and why it is, 
that in this affection, mental depression and prostration 
are such prominent symptoms: They are clearly the 
result of auto-ntoxication; the functions of the liver 
being inhibited by congestion and the toxic products 
from the intestinal canal being no longer arrested nor 
destroyed pass into the circulation inducing pronounced 
nervous symptoms, of which mental depression and pros- 
tration are the most prominent. If there are periods 
during the day in which nervous symptoms remit in 
splanchnic neurasthenia, such periods occur several 
hours after eating. Thus, in splanchnic neurasthenia, 
the ‘‘ fatigue curve” is not always identical with that 
which occurs in neurasthenia, the result of overwork. 
In the latter form of the affection, the ebb of nerve force 
begins with the early morning hours, attains its maxi- 
mum discharge in the middle of the afternoon, when the 


THE CAUSE AND CURE. 131 


nervously exhausted are most weak. Many splanchnic 
neurasthenics have and are being treated for a supposi- 
titious urte acid intoxication. Whatever organ may be 
aceredited with the manufacture of uric acid or the na- 
ture of the symptoms produced by the latter, this much 
is evident, that uric acid does no more in explaining 
gout than it does the nervous symptoms supposed to be 
attributed to it, but it hints at defective hepatic meta- 
bolism, or as Yeo *° would call it, “‘ hepatic inadequacy.” 
In other words, there is some disturbance in function 
antecedent to the accumulation of uric acid in the blood 
which is responsible for gout, rheumatism, neurasthenia 
and a multitude of allied affections. Experiments sug- 
gest the theory that urea and urie¢ acid are formed in 
the liver,** and admitting, for the sake of argument, 
that uric acid is responsible for the preceding affections, 
and that the source of its production is in the liver, rea- 
soning by analogy, this conclusion is warranted: that 
an organ in a healthy state which produces any sub- 
stance can also repress that substance when its over- 
production is inimical to the integrity of the economy. 
Approaching the final signs, which I have frequently 
encountered in splanchnic neurasthenia, we have insuffi- 
cient lung development and heart weakness. 

Insurricient Lune Dervetopment. Diminished 
intra-abdominal tension implies reduced strength of the 
diaphragm, and the elimination of this powerful muscle 
in respiration seriously compromises lung development, 
hence, in splanchnic neurasthenia, the lungs fail to per- 
form the work required of them, and another factor is 
added to further embarrass the already imperfect ab- 
dominal circulation. 

Heart Weakness. Here many factors conspire to 


132 THE BLUES :—NEURASTHENIA. 


bring about heart weakness. First, stagnation of blood 
in the abdomen means an insuflicient blood supply to the 
heart; second, there is a deficient supply of oxygen in 
the blood (Anoxemia), and the heart, like every tissue, 
suffers; third, the toxic substances present in the blood 
reduce the vital tone of the heart, and the resistance of 
the latter, like every other organ in the body, is neces- 
sarily reduced. In concluding this chapter, I wish to 
emphasize the very important fact, that splanchnie neu- 
rasthenia may exist without the appreciation of any 
abdominal symptoms by the patient; and on the other 
hand, while the local abdominal symptoms may be slight, 
the reflex symptoms may be so pronounced that they 
compromise the integrity of all the organs including the 
nervous system, the heart, the alimentary canaland the 
sexual organs. 


THE CAUSE AND CURE. 130 


SUMMARY, 


1. The dominant symptoms of splanchnic neuras- 
thenia are resident in the nervous system. 

2. Many splanchnic neurasthenics are never cogni- 
zant of abdominal symptoms; the latter being usually 
elicited by the physician in the course of his examina- 
tion. 

3. The chief abdominal symptoms are: Abdominal 
sensitiveness, tenderness of the liver and enlargement of 
that organ and gaseous accumulation in the bowels. 

4, It is often difficult to say how much of the nerv- 
ousness in the average neurasthenic is due to intra- 
abdominal venous congestion, for the latter condition 
may aggravate the symptoms of neurasthenia. The only 
test is the therapeutic one: by eliminating the venous 
element, which is certainly possible of achievement, we 
may observe the effect on the nervous symptoms. 

5. In splanchnic neurasthenia existing as an inde- 
pendent affection, the relief of symptoms almost posi- 
tively follows relief of the venous abdominal conges- 
tion. 

6. The Cardio-splanchnic phenomenon is a trust- 
worthy index of the severity of the affection, and in 
gauging the results of treatment. 

7. Splanchniec neurasthenia is specially encountered 
in individuals with vigorous constitutions, in whom the 
question of an unhygienic life does not enter into con- 
sideration. Nor can the conventional factors always be 
elicited in the history which conduce to neurasthenia. 


Sony 








Fig. 1.—Points of election on the abdominal surface, marked by 
crosses, for executing auto-massage. 


Te oe , 


cs 





ts 
uj 


CHAPTER VIII. 
THE TREATMENT OF SPLANCHNIC NEURASTHENIA. 


THE FUNDAMENTAL PRINCIPLES GOVERNING TREATMENT. 
THE PHYSICAL METHODS OF TREATMENT}; ABDOMINAL 
MASSAGE, ABDOMINAL EXERCISES, RESPIRATORY EXER- 
CISES, ELECTRICITY, ABDOMINAL SUPPORTERS, AND 
HYDROTHERAPY. — CITATION OF CASES OF SPLANCH- 
NIC NEURASTHENIA. — ACTION OF PURGATIVES IN 
SPLANCHNIC NEURASTHENIA. 


Tue primary and fundamental condition prevailing 
in splanchnic neurasthenia is a stagnation of blood in 
the splanchnic or abdominal veins. This condition is 
either primary or secondary to nervous exhaustion. The 
treatment then, must not only embrace the neurasthenic 
state, but the local condition of abdominal plethora. 
The general treatment of neurasthenia has already been 
discussed in Chapter V. This much is true, however: 
1. That if neurasthenia is dependent on congestion of 
the intra-abdominal veins, any treatment directed to- 
ward the former, however effective, will only result in 
temporary benefit. 2. Treatment directed toward the 
relief of abdominal congestion alone will often perma- 
nently arrest the neurasthenic symptoms. 3. Practically 
all cases of neurasthenia are associated with abdominal 
congestion, which serves to aggravate the neurasthenic 


137 


138 THE BLUES :—NEURASTHENIA. 


symptoms, insomuch as one of the earliest evidences of 
nerve waste is a diminished tone of the abdominal sym- 
pathetic. 4. There are many instances of abdominal 
congestion which never present the picture of neuras- 
thenia, but are manifested by an ill-defined group of 
symptoms, which baffle classification under any recog- 
nized form of disease. In any case, the relief and cure 
of abdominal congestion is imperative. I give expres- 
sion to a conservative statement when I say, that in no 
other form of neurasthenia are results achieved so posi- 
tively, quickly, and permanently, as in the splanchnic 
form of the affection. Here, our therapeutic maneuvers 
cannot bear the imprint of suggestion, for we can con- 
trol the results of treatment by certain objective signs 
which are indisputable, viz.: The reduction of hepatic 
enlargement, the disappearance of hepatic and abdom- 
inal tenderness, and the diminished grade of the Cardio- 
splanchnic phenomenon; and the gradual abatement of 
the objective signs run parallel with the evanescence of 
the subjective symptoms. We will now proceed to a dis- 
cussion of the physical methods which are designed to 
correct congestion of the abdominal veins. 

Puystcat Metuops wuicu Curr Sprancunic Nuv- 
RASTHENIA BY RELIEVING CONGESTION OF THE ABDOM- 
tNAL Verns: 1. Massage of the abdominal wall; 2. 
Hexercises which strengthen the abdominal muscles; 3. 
Respiratory exercises; 4. Electricity to the abdomen; 
5. Abdominal supporters; 6. Cold water. 

Massacre or THE Appominat Wau. When refer- 
ence is made to this maneuver, it does not signify the 
conventional massage, but a form of massage, executed 
by the patient, which achieves three distinct objects: 1. 
tt strengthens the abdominal muscles which, by their 


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THE CAUSE AND CURE. 141 


. 


augmented tone, increase intra-abdominal tension, thus 
clamping the intra-abdominal veins, as it were, and pre- 
venting their engorgement; 2. It facilitates the return 
of blopd from the abdominal veins to the heart; 3. It 
favorably influences reflexly the sympathetic nerve fibers 
which dominate the supply of blood to the abdominal 
organs. 

Meruop or AspomrnaL Massacre. 1. Method of 
. expulsion ; 2. Respiratory method. 

Mertuop or Exruuston. This method is designed 
for the comparatively strong subject, for it must be re- 
membered that abdominal manipulations of any kind act 
reflexly on the heart.* To aid in the elucidation of 
- this maneuver, reference is made to the accompanying 
illustrations: In figure 1, the abdomen is marked by 
erosses, which indicate the points of election for exe- 
cuting abdominal massage. In figure 2, the fingers are 
in contact with one of these points. The fingers of the 
left hand are first placed on the abdominal wall with a 
varying degree of pressure, which is re-enforced by su- 
perimposed pressure with the fingers of the other hand. 
The subject next endeavors, by contraction of the ab- 
dominal muscles, to overcome the pressure exerted by 
the fingers. This constitutes the complete act of auto- 
massage. It is repeated ten or more times over each 
spot, depending on the endurance of the subject. When 
the spots contiguous to the curvature of the ribs are 
reached, the fingers must be passed as far as possible 
under the ribs. The subject executes massage in the 
recumbent posture, as this position best favors the return 
of blood to the heart. The legs as seen in the illustra- 
tion are well drawn up to relax the abdominal muscles, 


* Appendix, Note 3. 


149 THE BLUES :—NEURASTHENIA. 


so that they may be more easily and powerfully con- 
tracted. The vigor of the massage may be gradually in- 
creased by increasing the pressure of the fingers and the 
number of manipulations over each spot. Massage exe- 
cuted after the foregoing manner may be followed by a 
sense of oppression in the heart region and fulness in 
the head, sensations which may be referred to over-dis- 
tension of the heart, due to the large quantities of blood 
expressed into this organ from the abdominal veins. 
After each contraction of the abdominal muscles, the 
subject should take a forced deep breath, so as to suck 
the blood into the lungs from the engorged right heart: 
an act which will easily remove and prevent the sensa- 
tions already referred to. The sensation of tingling, 
which the patient experiences in the extremities during 
massage, are rather pleasant than otherwise, and may 
be referred to an improved circulation. Soreness of the 
abdomen after initiation of the exercises may be dis- 
regarded, being provoked by contraction of muscles un- 
accustomed to exercise. 

Resprratory Mertrnop. This is a maneuver less 
harsh than the former, having for its goal the same ob- 
jects, and designed for subjects in whom the heart-action 
is not strong. As in the expulsion method, the fingers 
are placed in succession over each spot with a varying 
degree of pressure and by a forced act of inspiration 
only, the patient endeavors to remove the pressure ex- 
erted by the fingers. maneuver may be repeated 
over each spot a varying number of times, and the finger 
pressure increased or diminished, according to the en- 
durance of the subject. There are certain facts worthy 
of mention in reference to this form of auto-massage. 
As a rule, splanchnic neurasthenics suffer from hemor- 


On 


THE CAUSE AND CURE. 143 


rhoids, and this is not extraordinary, considering the 
engorgement of the abdominal veins. Auto-massage will 
eure such hemorrhoids, not only in neurasthenics, but 
in others, and I know of no simpler nor more effective 
measure for the relief and cure of this obstinate affec- 
tion. In reference to auto-massage on the action of the 
bowels, all I can say is this, that some splanchnic neu- 
rasthenics obtain relief from their constipation, others 
find no relief, whereas. others, who are not constipated, 
increase the number of their bowel movements. In 
any event auto-massage will do much toward augment- 
ing the tone of the intestines. 

EXERCISES WHICH STRENGTHEN THE ABDOMINAL 
Muscirs. These exercises may be employed in con- 
junction with auto-massage, or either may be executed 
to the exclusion of the other, although if either method 
is employed alone, preference is given to auto-massage. 
Exercises for developing the abdominal muscles must 
be regulated in duration and number by the age and 
strength of the patient. 

These exercises should be avoided if hernia exists, 
unless primarily supervised by the physician. 

Exercise 1. Rope-hauling exercise. Two strong 
elastic cords, two feet in length and fixed into the floor 
at one end, while to the free end rings are attached 
which can be grasped by the hands. These cords are 
stretched alternately by first pulling with one and then 
with the other hand, as in rope-hauling. 

Exerrcisr 2. The patient lies on the floor and places 
his feet against some resisting object, and then attempts 
to assume the sitting posture. This exercise may be 
repeated a number of times, When the patient begins 


144 THE BLUES :—NEURASTHENIA. 


the exercises, he may assist himself in rising by aid 
of the hands. 

Exercisr 3. This requires the aid of an assistant. 
‘The patient, seated on a stool, bends his body back- 
wards and forwards. The forward movement is resisted 
by the assistant, who grasps the shoulders from behind. 

Exercise 4. The patient sits on a stool with his 
back to the wall. On either side of him is a ring fixed 
into the wall. Through each ring a cord passes, to the 
ends of which weights are attached. The portion of 
cord between the two rings is passed round the waist. 
The body is then repeatedly bent toward the thighs and 
the weights thereby raised. (Campbell. ) 

STRENGTHENING THE AxBpoMINAL MuscLEes BY 
Means oF AN Exerciser. I have devised a simple ap- 
paratus (see illustrations, figs. 8 and 4), which I regard 
as most serviceable in this connection. ‘The work put 
upon the abdominal muscles by means of this apparatus 
ean be regulated to any degree, depending on the amount 
of traction put upon the elastic cords. It consists of 4 
pieces of elastic cord, each one-half inch in width and 
about 5 feet in length; a firm though yielding belt of 
leather, very smooth on the surface, brought in contact 
with the abdomen 4 inches in width and tapered at 
the ends and provided with strap and buckle for fixation 
around the abdomen; two blocks of wood, provided with 
4 holes for the elastic cords, each piece five inches in 
width and about an inch in thickness. To each block 
of wood a piece of firm leather is screwed, leaving a 
projecting loop, which, in appearance, is not unlike a 
stirrup. The leather stirrups are intended for the at- 
tachment of snaps. The elastic cords are fixed by means 
of a knot in each hole in one block of wood,-the cord in 





Fig. 3.—Apparatus for Fig. 4.—Method of using the apparatus 
abdominal exercises. for abdominal exercises. 





THE CAUSE AND CURE. 147 


contact with the holes being wound with fine wire to pre- 
vent wear; then they pass across the front of the leather 
belt, and to prevent slipping, across the belt three nar- 
row strips of leather, vertically attached by means of 
rivets, are placed, with apertures for the cords; then 
the cords are passed through the holes of the other 
block ‘of wood, and fixed by means of knots, and here 
likewise re-enforced by wire. The apparatus is then ° 
attached to two screw eyes in the wall, when it is ready 
for use. 

The elastic cords, shown in the illustration, are cov- 
ered with webbing, and after a limited use of the ap- 
paratus, become worn, leaving the rubber free. This 
is a serious objection, and for this reason, solid rubber 
cords, two in number and about one inch in width may 
be employed; otherwise, the apparatus is made accord- 
ing to the description already given. It is a matter of 
little moment what kind of apparatus is employed, pro- 
vided it permits of regulated abdominal traction. 

The belt of the apparatus is first placed below the 
navel and tightened by means of the strap and buckle; 
then the patient steps forward on a board placed on the 
floor, which is provided with cleats arranged at conven- 
ient distances. The real work is executed while stepping 
forward, the backward movement being effected by the 
elasticity of the cords. The number of tractions made 
by the abdomen is regulated by the strength and en- 
durance of the patient. After the lower abdomen is 
exercised, the belt is fixed successively on the navel, and 
then above the navel, so that all parts of the abdominal 
muscles may be included in the exercises. I advise 
my patients that, after each traction by means of the 
abdomen, a deep inspiration should be taken to prevent 


148 THE BLUES :—NEURASTHENIA. 


accumulation of blood in the heart and to further its 
circulation through the body. I further advise my 
patients to exercise after rising and before retiring; to 
begin with 10 tractions, in each position of the belt, viz. : 
below, at and above the navel, 30 in all; and to grad- 
ually increase the number to 75. 

Resprratory Exercises. We have already referred 
in a previous chapter to the great value of pulmonary 
ventilation, in preventing disease and maintaining the 
standard of health. The lungs are important avenues 
for the elimination of poisonous substances generated 
within the body; they regulate the local and general 
blood and lymph circulations, not only in a quantita- 
tive, but in a qualitative manner. Without properly de- 
veloped lungs, no individual can be regarded as healthy. 
While general exercises may and do contribute to res- 
piratory gymnastics, the character of the exercises is 
such that it is more than the average patient can do, 
hence local pulmonary gymnastics are necessary for the 
preservation of health. We have already shown that the 
mere act of inspiration performs a double function in 
relieving abdominal congestion, viz.: The descent of the 
diaphragm, by increasing intra-abdominal tension, 
squeezes the blood out of the intra-abdominal veins into 
the heart; inspiration favors pulmonary suction, for 
during this phase of respiration, the blood-vessels of the 
lungs are expanded, and the blood is sucked, not only 
out of the abdominal veins, but from the veins through- 
out the body. It is only rarely in health that the lungs 
in their entirety are physiologically active, and this 
question is further discussed in the appendix.* Both 
phases of respiration may be influenced by respiratory 


* Appendix, Note 1. 


THE CAUSE AND CURE. 149 


gymnastics, viz.: inspiration and expiration or both. 
In the average case, it may be presumed that when in- 
spiration is vigorous, expiration is equally vigorous, but 
in those predisposed to pulmonary tuberculosis, we may 
have, as my investigations show, a voluminous lung capa- 
ble of performing the act of inspiration with normal 
vigor, and yet the expiratory act may be seriously com- 
promised.* Here attention will be directed to a simple 
exercise for facilitating inspiration, and it may be exe- 
cuted in conjunction with the use of the abdominal ap- 
paratus previously described. I believe I am justified 
in protesting against prolix methods for securing lung 
development. Such methods accomplish little and de- 
feat their object, which cause them soon to be relin- 
quished. The Roentgen rays have furnished me with 
indisputable proof in selecting simple methods for in- 
flating the lungs. | 

It is well known that the lungs in health appear in 
the fluoroscopic picture as light areas. The lungs ap- 
pear brighter during inspiration than expiration; in 
fact, the greater the lung inflation, the brighter the 
reflex. I have examined patients with the fluoroscope 
during the time “ breathing tubes ” were used, and while 
the different postures and exercises were practiced, as 
advocated by various writers, and I was unable to dem- 
onstrate that any method was superior to that of forced 
breathing. In fact, in some of the advocated methods, 
the fluoroscope ‘Lama the lung phase to be alee 
that of expiration, whereas, the shee supposed to be 
attained was lung inflation. To enhance the value of 
forced inspiration with the object of attaining hyper- 
ventilation of the lungs, the simple expedient of holding 


* Appendix, Note 7, 


150 THE BLUES :—NEURASTHENIA. 


the breath after full inspiration will be found of great 
value. After a little practice, patients are able to hold 
the breath fully two minutes. If, during this maneuver, 
regional percussion is made, it will be found that the 
position of the lung borders extend beyond the limits 
attained by forced inspiration alone. The principle in- 
volved in explanation of the foregoing phenomenon is 
one relating to pneumatics, by raising the temperature 
of a gas we increase the volume. Another simple 
maneuver is to direct the patient, after taking a forced 
inspiration, to count slowly. With a little practice, 80 
ean be counted without difficulty. This is an exercise 
both for the inspiratory and expiratory forces. For rapid 
lung development, inhalations of compressed air by the 
aid of the pneumatic cabinet, is unquestionably the best 
method. After a limited course of treatment the tho- 
racic capacity may be increased 2 per cent., with a cor- 
responding development both of chest measurements and 
chest expansion. 

The method which I earnestly advocate, when used 
in connection with the abdominal exerciser, is that em- 
ployed by the Swedish trainers, and after each or several 
tractions are made by the abdomen, this exercise is 
executed. It is as follows: The patient raises his arms 
to the vertical position, at the same time taking a deep 
inspiration. He then brings the arms downward and 
backward, thus describing a large movement of circum- 
duction. When the patient practices forced inspiration, 
he supports himself on his toes, inclining his body back- 
ward during the entire period of inspiration. 

Evectriciry To THE ABpomEen.* Of all methods, 
this is unquestionably the most expeditious and thor- 


* Appendix, Note 13. 


ed 


THE CAUSE AND CURE. 151 


ough-in the treatment of splanchnic neurasthenia, and 
were I less conservative, I would regard it as a specific 
measure. I have tested all forms of electricity, physi- 
ologically and therapeutically, in relation to this special 
affection, viz.: Galvanic, faradic, static and high fre- 
quency, but they are all subservient in their action to the 
Sinusoidal Current. 

The Sinusoidal Current * acts differently upon the 
body from other forms of current, and this is due to the 
number of alternations in a second, the quantity of cur- 
rent, and the degree of electro-motive force. Owing to 
the uniformity of the alternations, strong currents may 
be employed without producing pain or muscular con- 
tractions. The sinusoidal current possesses the prop- 
erty of contracting the organs, specially the heart, in- 
ducing what I have ealled the heart reflex, the lungs 
(lung reflex of contraction) and the liver (liver reflex).t 
It is also endowed with the property of contracting the 
veins, notable the intra-abdominal veins and of stimu- 
lating the sympathetic abdominal nerve fibers. 

The effect of this current in driving the blood from 
the intra-abdominal veins back into the heart is evi- 
denced by the eardio-splanehnic phenomenon, which is 
elicited to a remarkable degree after its application. 
The sinusoidal current, by the uniformity of its alterna- 
tions, anesthetizes the terminal sympathetic nerve fibers 
and this anesthesia is so marked in the skin between the 
electrodes that no sensation is experienced by the pa- 
tient, even after a pin prick during the application of 
the current. 

My usual method of application is to place one large 


* Appendix, Note 6. 
+ Appendix, Note 13. 


152 THE BLUES :—NEURASTHENIA. 


electrode above and another below the navel and fix 
them in position by means of straps. The duration of 
each application made daily must not be less than 15 
minutes. Not infrequently while one electrode is ap- 
plied to the abdomen the other may be applied to the 
back of the neck, specially if the patient complains of 
pains radiating to the back of the neck. Each applica- 
tion is, as a rule, followed by a sensation of well-being, 
which is never attained so expeditiously by any other 
method of treatment. The strength of the current should 
be as strong as the patient can tolerate, but never too 
strong to induce unpleasant sensations. 

I have also employed vibratory massage of the ad- 
domen by means of a vibratory machine, as.a substi- 
tute for the sinusoidal current, but the effects can in no 
wise be compared to the current. . 

ABDOMINAL Supporters. The use of a properly- 
fitting abdominal support or belt is only to be thought 
of when the abdominal muscles are relaxed beyond the 
hope of restoration by electricity, exercise, massage, ete. 
There can be no objection, however, to use a support 
in connection with the methods already referred to for 
strengthening the abdominal muscles. The physician 
should examine the support to determine whether it 
merits its name, insomuch as the majority of abdominal 
supporters on the market are worse than useless. In 
dislocation of the abdominal viscera (lWnteroptosis) the 
wearing of an abdominal supporter affords much relief 
to the wearer. The relief thus attained is not due 
wholly to reposition of the organs, as is instanced in the 
observations of Bial.?® The latter applied transparent 
bandages to cases of gastroptosis and transilluminated 
the stomachs before and after the application of the 


THE CAUSE AND CURE. 153 


bandages. No change in the position of the stomach 
could be noted, and it is therefore most likely that ab- 
dominal supporters act chiefly by compression of the 
viscera, Which in turn squeeze the blood out of the 
turgid abdominal veins. 

CoLtp Water. After the morning exercises with the 
abdominal apparatus, I insist on my patients taking a 
lukewarm bath, or even a cold bath, if they are accus- 
tomed to it, and by means of a spray douche direct cold 
water from a certain height to fall on different parts 
of the abdomen. This is a most effective means of aug- 
menting the tone of the abdominal walls, and organs 
and tissues of the abdomen. The circulation of the 
blood, the motion of the alimentary canal and the process 
of nutrition are thus stimulated reflexly by innumerable 
nerves which terminate in the skin. 

In concluding the subject of treatment for splanchnic 
neurasthenia, it may be mentioned for the sake of com- 
pleteness, that, when the anterior abdominal wall is be- 
yond hope of repair, owing to its flabby and relaxed 
condition, an operation may be suggested for its resec- 
tion. ‘This operation has been performed with success 
by different surgeons. I have selected ten cases among 
my splanchnic neurasthenics to illustrate the effects of 
treatment according to the lines already laid down. 


Casz 1. Vertiginous Symptoms. Merchant. Age 
42. Pronounced symptoms of neurasthenia. The chief 
symptom is vertigo, which has increased of late to such 
a degree that he fears to go out without a companion. 
One evening he had eaten too heartily of fresh fruit, 
with the result that he developed an attack of intestinal 
colic, and his vertigo became very much intensified. He 


154 THE BLUES :—NEURASTHENIA. 


noted with much surprise that the pressure of his wife’s 
hands on his abdomen, while relieving his symptoms of 
colic, likewise gave temporary relief to his vertigo. His 
wife suggested the application of a bandage to his ab- 
domen, with the result that as long as the bandage was 
worn, the vertigo disappeared. After recovery from his 
colic, he was able to go about unattended, provided he 
wore a closely-fitting leather belt around his abdomen, 
and if this belt were removed, the signs of vertigo would 
recur. This case suggested to me the pertinent fact, 
that the patient in question owed his vertiginous attacks 
to gravitation of blood to the splanchnic area, and that 
the application of his leather belt merely forced the 
blood from the latter area into the general circulation. 
After one month’s treatment by means of the sinusoidal 
current, daily applications, supplemented by abdominal 
and respiratory exercises, the patient dispensed with his 
leather belt, and was, in fact, cured. In this and other 
cases, it is difficult to say how permanent the cure really 
is, and for this reason, I enjoin my patients to continue’ 
their exercises for an indefinite period. 

Case r. Chief symptom, pain radiating to the arms 
and legs. Tailor; age 38. Has been unable to follow 
his oceupation for the last eight months, owing to par- 
oxysms of pain, which radiate to the neck, arms and 
legs. His arms feel “ like paralyzed,” and legs seem 
unable to support his body. Has headaches. Suffers 
from gas in the stomach and bowels. Has been losing 
in weight, and cannot sleep. Has been subjected to 
almost all kinds of treatment by different physicians, 
without any relief. Examination shows an enlarged and 
sensitive liver, in fact, palpation of this organ almost 
“causes him to faint.” His abdominal wall lacks tone., 


THE CAUSE AND CURE. LD 


Treatment by means of the sinusoidal current, one elec- 
trode to the back of the neck and the other to the abdo- 
men, supplemented by exercises, has enabled him, after 
five weeks treatment, to return to work. 

Caszr ur. Mental symptoms. Clerk; aged 29. Has 
had syphilis. Has a feeling of pressure on the top of his 
head. He is in constant dread that “‘ something is going 
to happen.” Feels as though something were lodged 
_in his “ belly,” and that by taking a deep breath he is 
able temporarily to dislodge it. While in my presence 
during his early visits to my office, he was constantly 
engaged in taking forced inspirations. Ilis memory is 
poor, and he is unable to concentrate his attention on 
anything. Examination demonstrated the conventional 
stigmata of splanchnic neurasthenia. This patient had 
taken three rest cures and for more than a year had 
traveled about the country in search of health. After 
two months’ treatment, he was able to resume his work, 
when he said “ I never felt better in my life.” 

Casniv. Chief symptoms, depression and weakness. 
Woman; married; age 46. Could not be persuaded to 
leave her bed on account of extreme weakness. Was 
very much depressed, and feared that her relatives were 
going to take her to an insane asylum. She eats only 
sparingly, contending that food distresses her. Her his- 
tory prior to her illness, which has been gradual in its 
approach, was uneventful. Examination showed no 
liver enlargement nor tenderness. There was only one 
point of abdominal tenderness. Pressure on the ab- 
domen, kept up for several minutes, demonstrated the 
eardio-splanchnie phenomenon to an unusual degree. 
Treatment was begun with the sinusoidal current to the 
abdomen, and after two weeks, she could be persuaded 


156 THE BLUES :—NEURASTHENIA. 


to take the other exercises, with the result that in three 
months she was discharged as cured. 

Case v. Prominent symptom, pain in the liver 
region. Woman; married; age 43. Is very much de- 
pressed on account of pains in the region of the liver. 
“ Bloats ” after eating. Has symptoms of indigestion. 
Is constipated. Liver enlarged and tender. Abdominal 
points of tenderness. After two weeks treatment pa- 
tient returned home and, as she said, “ completely 
cured.” 

Case vi. Prominent symptom, “ the blues.” Elec- 
trician; age 40. Has no symptoms beyond attacks of 
“the blues.” Knows no cause for their occurrence. 
The attacks may last a week, during which period he is 
unfit for his occupation. Examination reveals the stig- 
mata of splanchnic neurasthenia. Self-treatment by 
massage and exercises. The result of treatment has 
been that his blues, as he says, “ are now a matter of 
history only.” | 

Casz vu. Chief symptom, impotency. Teacher; 
age 81; married. Very nervous and irritable. Always 
depressed.’ Worries about his sexual condition. Has 
attempted suicide. Associates his impotency with intes- 
tinal indigestion, insomuch as he finds that whenever 
he belches much gas, his sexual condition is worse. 
Stigmata of splanchnic neurasthenia. Self-treatment by 
massage practiced twice daily. After the third treat- 
ment; improvement became manifest, and after four 
weeks, he asserted that his sexual power was restored. 

Casr vit. Prominent symptom, palpitation of the 
heart. Banker; married; age 53. Suffered for years 
from palpitation of the heart. Attacks have become 
more frequent and of longer duration. Worse after 


THE CAUSE AND CURE. 157 


eating. Cardiac palpitation is associated with symp- 
toms of indigestion. Fears that he has heart disease. 
Has consulted many prominent physicians in this coun- 
try and Europe. Has submitted to all kinds of treat- 
ment, including a rest cure, lasting three months. Liver 
not enlarged. No signs of organic heart disease. No 
abdominal points of tenderness. Pulse rate, 90 per 
minute, and can be reduced to normal after repeated 
pressure on the abdomen. Treatment by means of the 
sinusoidal current, and cure after three weeks treatment. 
It may be remarked incidentally, that in this patient, 
there were no stigmata of splanchnic neurasthenia, be- 
yond the exaggerated presence of the cardio-splanchnic 
phenomenon, and this is the only clue to the affection in 
a number of cases. 

Case 1x. Prominent symptom, indigestion. Capi- 
talist; aged 62. Very much depressed and generally 
nervous. Has a constant burning in the stomach. Does 
not eat much on account of the food, which distresses 
him. Has lost 25 pounds in weight. Nothing relieves 
him. Has a pendulous abdomen. The stomach is di- 
lated and dislocated. The liver is very much enlarged, 
and is very sensitive to pressure. Abdominal points of 
tenderness. ‘Treatment, sinusoidal current to the ab- 
domen and auto-massage. JRelef after one week and 
cure in seven weeks. 

Casr x. Prominent symptom, morbid fears. 
Woman; aged 28. Fears crowds and open spaces. Will 
not handle door knobs, fearing infection. Very irritable 
and “blue.” Symptoms of indigestion. Faints easily. 
Has headaches, and is constipated. Purgatives inten- 
sify her symptoms, therefore, she allows herself to re- 
main constipated rather than take a purgative. Exami- 


158 THE BLUES :—NEURASTHENIA. 


nation reveals all the characteristic symptoms of splanch- 
nic neurasthenia. Treatment by auto-massage resulted 
in cure. 

Action oF PurGATIvVEs IN SpLaANcHNIC NEURAs- 
THENIA. ‘The recital of the last case directs our atten- 
tion to the use of purgatives in this particular affection. 
As a rule, physicians, presuming that these cases respond 
in their symptomatic make-up to intestinal auto-toxemia, 
have habitual recourse to intestinal antiseptics and ca- 
thartics. Now, cathartics in such subjects, in my ex- 
perience, act unfavorably, for they induce a feeling of 
faintness or vertigo and intensify the nervous symptoms. 
The reason for all this is evident. Cathartics induce, by 
their action, the determination of an increased supply 
of blood to the abdominal organs, thereby augmenting 
the symptoms dependent on congestion of the intra-ab- 
dominal veins. J know several individuals who are con- 
strained to defecate in the recumbent posture, other- 
wise they will suffer from faintness. The faintness ex- 
perienced by persons when they first assume the vertical 
posture after a prolonged illness owes its genesis to the 
same cause which operates in the instances already 
mentioned. Hull and Barnard °° have shown the in- 
fluence of gravity on the circulation and the part per- 
formed by the abdominal muscles in preventing the 
eravitation of blood into the splanchnic veins. They 
demonstrated that when the splanchnic vasomotor mech- 
anism was intact, it was able to prevent such gravitation, 
but when this mechanism was destroyed by section of the 
splanchnic nerves, a second mechanism was brought into 
operation, consisting of expiratory compressions of the 
abdomen, occurring simultaneously with inspiratory 
thoracic suctions, the former squeezing, the latter suck- 


THE CAUSE AND CURE. 159 


ing the blood out of the splanchnic pool. Now faint- 
ness occurring when the vertical posture is assumed, 
means any one of three things, viz.: Diminished intra- 
abdominal tension from relaxed abdominal walls, di- 
minished thoracic suction or an enfeebled state of the 
splanchnic vasomotor system. The loss of one mechan- 
ism may and often is compensated by another. 

The mechanism consisting of abdominal compressions 
' in expiration and thoracic suctions in inspirations, as 
well as the splanchnic vasomotor mechanism, may be 
destroyed by division of the cord at the first dorsal verte- 
bra. If the animal operated on be then held vertically 
with the head up, all the blood will collect in the splanch- 
nic veins, and the empty heart continues vainly to beat; 
but after compressing the abdomen, the blood is squeezed 
into the heart, thus restoring the circulation. 





CHAPTER IX. 
INTESTINAL AUTO-INTOXICATION. 


WHAT Is INTESTINAL AUTO-INTOXICATION ?—FOOD.—THE 
ORGANS OF DEFENSE.—FACTORS DETERMINING AUTO- 
INTOXICATION.—SYMPTOMS OF AUTO-INTOXICATION, — 
THE DIAGNOSIS OF AUTO-INTOXICATION.—HEPATIC IN- 
SUFFICIENCY.——TREATMENT OF INTESTINAL AUTO-INTOX- 
ICATION, 


E:sewuHerr,* I have been rather conservative in 
formulating conclusions respecting the significance of 
auto-intoxication as a causative factor in neurasthenia. 
Since then, however, many notable investigations 
have endowed this subject with so much importance 
that it dare not be ignored by the physician in the 
treatment of his neurasthenic patients. Although 
there are many neurasthenics who react favourably to 
the methods of treatment suggested in this book, yet, 
there are many others, who demand in addition, a 
method of procedure which aims to minimise intestinal 
putrefaction. 

Wuar is Intrestrnan Avto-Iyroxication? Poisons 
are common to animal and plant life and the human 
body contains the most deadly poisons which are made 
innocuous by physiologic metabolism. We have phos- 
phorus in the bones and blood, hydrochloric acid in 
the stomach, potassium sulphocyanide in the saliva 
and even arsenic is found as a normal ingredient. 

* Vide, page 45, 

11 161 


162 THE BLUES :—NEURASTHENIA. 


Brunton, in ‘‘ Lectures on the Action of Medicines,”’ 
tells us, that the saliva of some men is nearly as pois- 
onous as the venom of a serpent and he assures us 
further, that the juice of various glands when injected 
directly into the blood will kill an animal as quickly 
as a rifle-bullet. The poisons of man are manu- 
factured normally in the intestines. The most im- 
portant ingredients of the digestive secretions are the 
ferments. Thus we have pepsin in the gastric juice; 
trypsin and other ferments in the pancreatic juice and 
enterokinase in the intestinal juices. These ferments 
convert various kinds of food into more soluble and 
diffusible products. In addition to the digestive fer- 
ments, digestion is facilitated by the bacteria normally 
inhabiting the intestinal canal. The bacteria of the 
human intestine increase at the rate of 128,000,000,- 
000,000 each day and the bacterial flora constitutes 
one-third of the human excreta. It has been shown 
that the presence of germs is not absolutely essential 
for our well-being; indeed, digestion of varied kinds 
of foods is possible even when made sufficiently sterile 
to exclude germs from the alimentary canal. Now, it 
is a well-known fact, that even when normal products 
of digestion lke peptones and albumoses are injected 
directly into the blood, they are very poisonous, and 
even fatal, in their effects. The production of toxic 
substances in the alimentary canal is augmented by bac- 
terial action which gives rise to fermentation and putre- 
faction. Whereas the normal ferments of the digestive 
fluids produce intestinal poisons or enterotoxins, we are 
chiefly concerned with the poisonous substances ema- 
nating from microbic putrefaction. One must by no 
means conclude that putrefactive processes are neces- 


THE CAUSE AND CURE. 163 


sarily harmful, on the contrary, the danger is only 
manifested when they are excessive. Thus in the 
norm, such processes assist: digestion and inhibit the 
entrance of poisonous products into the body. Leci- 
thin, for instance, is found in large quantities in egg- 
yolk and by the action of the pancreatic juice it is 
broken up into many ingredients, notably, a poisonous 
ptomain, known as cholin. We are, however, pro- 
tected from the toxic action of the latter, by the bac- 
teria which convert it into inoffensive products. 

Foop.—All food can be classified as follows: 

1. Proteid oralbuminous food. The flesh of animals 
consists chiefly of proteid and ordinary lean _ beef 
contains about 20 per cent. Kees contain about 10 per 
cent. of proteids. 

2. The carbohydrates or sugary foods (sugar and 
starches). 

3. Fats of animal and vegetable origin. 

We will limit ourselves to a brief discussion of the 
toxic products derived from albuminous foods for the 
reason, that they are chiefly concerned in the morbid 
phenomena of auto-intoxication and for the additional 
reason, that the biologic chemistry of the carbohy- 
drates and fats is imperfectly understood. 

It is often difficult to say when the action of the 
intestinal juices ends and when bacterial action begins 
but, it has been practically established that microbic 
disintegration of the albuminous molecule results in 
the formation of fatty acids and amino-acids, especially 
leucin and tyrosin, substances producing a vile odor 
like indol, phenol and skatol (belonging to the aromatic 
series of compounds), as well as certain gaseous products. 

Experiments have demonstrated that the putrefac- 


164 THE BLUES :—NEURASTHENIA. 


tion of the albuminous molecule is limited in the norm 
to the large intestine but, in instances of intense 
putrefaction, it may commence in the lower part of 
the small intestine. The upper small intestine in 
fasting animals is practically free of microbes. 

It has been shown that only six-sevenths of the 
albuminous food ingested is assimilated in the small 
intestine whereas the balance becomes the prey of the 
microbes. Among the toxic aromatic products of in- 
testinal putrefaction is ¢mdol. The latter when given 
to normal individuals even in small doses may produce 
frontal headaches, nervous irritability and restlessness 
and induces when administered in larger doses, diar- 
rhea, insomnia and mental restlessness. 

The continuous administration of indol in doses 
large enough to betray its presence in the urine can 
produce symptoms of neurasthenia and, there is no 
longer any question among competent clinicians, that 
the absorption of this substance from the products of 
intestinal decomposition is responsible for many cases 
of this disease. 

Tue Orcans or Drerense.—In the norm, the poison- 
ous substances in the intestinal canal are either not 
absorbed or they are made innocuous and rapidly ex- 
creted. Auto-protection of the organism against 
self-poisoning is achieved either by organs which 
arrest or transform the poisons or eliminate them. 
The organs of defense practically represent the bodily 
resistance. This equationally expressed for germ in- 
fection is applicable to auto-intoxication, v7z., 

eilebaee 
CEA 
D, the disease, equals P, the poison, multiplied by T, 


THE CAUSE AND CURE. 165 


its toxicity, multiplied by A, its amount, the product 
being kh, the resistance of the individual attacked. 
The organs which arrest the poisons are the liver, 
spleen, gastro-intestinal mucous membrane, lymph- 
glands, adrenal bodies, thyroid gland, etc. The liver 
is the chief organ of defense. It converts the poisons 
into non-toxic and assimilable substances, filters them, 
and excretes them in the bile. If the liver is excluded 
from the general circulation by connecting the portal 
vein with the inferior vena cava, nervous manifesta- 
tions, and even death may follow the ingestion of 
meats. The organs of elimination are the skin, lungs, 
kidneys, and intestines. Body-elimination by the 
various excretory channels has been divided as follows: 
By the lungs, 32 per cent; by the kidneys, 46-47 per 
cent; by the skin, 17 per cent, and by the feces, 5-9 
per cent. | 

Bacteria are regularly conveyed to the stomach with 
the food, but their growth is generally inhibited by 
the hydrochloric acid of the stomach. The food 
passing quickly from the small to the large intestines, 
an insufficient time is allowed for the bacteria to 
multiply. The normal epithelial cells of the intes- 
tinal mucous membrane also protect the organism and 
there is reason to believe, that they contain a sub- 
stance (probably nucleinic acid) which possesses an 
antibacterial action. Even though the toxic products 
of bacterial action pass through the intestinal mucous 
membrane, it is assumed that such toxins protect the 
individual against the virulent action of the bacteria 
from which they are derived. 

We know that after a meal the white blood- 
corpuscles increase in number (digestive leucocytosis), 


166 THE BLUES :—NEURASTHENIA. 


and we also know, that nearly all intoxications and 
infections produce the same result. Proteid food in- 
fluences the result more than farinaceous food or a 
mixed diet. In some diseases of the stomach and in- 
testines, this post-digestive leucocytosis does not occur. 
It may be assumed that in health, the organism pro- 
tects itself against the absorbed products of bacterial 
action by an increase in the number of white corpuscles 
which remove and destroy the toxic substances. It 
is evident from what has preceded, that the intestinal 
canal is a permanent source of intoxication and that 
were it not for the organs of defense, one would con- 
stantly suffer from the symptoms of self-poisoning. 

Factors Wuich Derrermine Avto-[nroxicaTion.— 
The essential condition always present in auto-in- 
toxication is a reduction in the antitoxic function of 
the organs of defense. There are, however, predispos- 
ing conditions favoring this reduction of normal 
functional activity, one of the most important of which 
is the condition prevailing in splanchnic neurasthenia, 
viz., congestion of the veins of the abdomen. When 
the latter is present, it interferes with a proper supply 
of arterial blood, and in consequence the tissues and 
organs are bathed in pools of stagnant blood-—TZhey 
are practically asphyxiated. Again, the impeded cir- 
culation cannot remove the toxic products of digestion 
and bacterial action and, instead of the latter being at 
once conveyed to the organs of elimination like the 
kidneys, they are arrested or transformed by the 
organs of defense which soon prove inadequate to dis- 
charge their anti-toxic function; and then we have 
the creation of symptoms which belong to the category 
of self-poisoning. 


THE CAUSE AND CURE. 167 


Excessive albuminous food, that is to say, a diet 
containing a large quantity of meat and eges aug- 
ments intestinal putrefaction and even though the 
organs of defense are relatively normal they are inca- 
pable of performing their functions when an increased 
burden is thrust upon them. 

Factors which retard the absorption of the products 
_of digestion favor auto-intoxication for the reason that 
if they are not absorbed they become a prey to the 
action of the intestinal microbes. It has been shown that 
the ingestion of fluid during a repast hinders digestion 
and this like any other factor which will retard diges- 
tion, paves the way for intestinal putrefaction. The 
gastric juice inhibits the virulence of the intestinal 
microbes and, if for any reason, the juice in question 
is abnormal, intestinal putrefaction is encouraged. 

The biliary acids are endowed with antiputrefactive 
properties and any anomaly in the biliary secretion 
will likewise favor intestinal putrefaction. 

It suffices to say that all affections of the digestive 
apparatus by interfering with digestion will favor in- 
testinal putrefaction and any condition favoring the 
latter conduces to auto-intoxication. Again, constitu- 
tional conditions may favor self-poisoning by reducing 
the functional activity of the organs of defense. 
Organs of elimination like the kidneys which are de- 
fective cause the retention of toxic products which 
should be excreted and are in consequence also respon- 
sible for the symptoms of auto-intoxication. 

The majority of people dig their graves with their 
knives and forks, and Dr. Abernethy observed, 
‘There is no beast of burden in the world so over- 
loaded as the human stomach.”’ 


168 THE BLUES :—NEURASTHENIA. 


Talmage remarked, that, ‘‘ Many a man is trying to 
do by prayer what can only be done by correct diet.”’ 

Many individuals start out in life with adequate 
organs of defense but over-eating soon makes them in- 
sufficient. 

There are still others with congenitally defective 
organs of defense or who possess through some anomaly 
of heredity an insufficient digestive apparatus. 

Symproms oF Inrtestinan Avto-Iyroxication.—lf 
one were guided in the diagnosis of auto-intoxication 
by the statements of the patient, the condition would 
rarely be recognized. The fact is, the patients infre- 
quently complain of symptoms of indigestion. They 
usually inform us that their digestion is perfect. To 
the lay individual, dyspepsia signifies, lack of appetite 
or discomfort and flatulence or acidity after eating. 
It is only in aggravated cases that one encounters the 
conventional symptoms of indigestion. In most in- 
stances nervous symptoms precede the local symptoms 
of indigestion. The symptoms are initiated by par- 
oxysmal attacks of headache localized either in the 
frontal or occipital region, by attacks of migraine, by 
attacks of fatigue, depression and other neurasthenic 
symptoms until eventually the symptoms become con- 
tinuous and the classical picture of neurasthenia (toxic 
neurasthenia) is developed. In association with the 
neurasthenia, the nutrition suffers and wasting is a 
prominent symptom. Not infrequently alternating 
attacks of diarrhea or constipation may direct the pa- 
tient’s attention to the digestive apparatus. The 
majority of patients cannot account for their nervous 
symptoms. By closely questioning many of these pa- 
tients one may elicit much valuable information. The 


THE CAUSE AND CURE. 169 


mere fact that an attack of diarrhea has succeeded an 
unaccountable period of depression will suggest auto- 
intoxication. In other instances, a paroxysm of irrita- 
bility, imsomnia, fatigue or headache has followed the 
ingestion of some particular kind of food to which the 
patient was unaccustomed. 

In still other instances, although neurasthenic symp- 
toms are always present, they become accentuated 
after hasty or excessive eating, a late supper, the in- 
gestion of particular kinds of food or after the use of a 
purgative (page 158). As a rule, the symptoms de- 
velop on the following day or even several days after 
the dietetic indiscretion. It is for the latter reason, 
that the patient is unable to trace any connection be- 
tween his nervous symptoms and his faulty digestive 
apparatus. In these cases even in the absence of the 
symptoms of indigestion, the physician will be able to 
elicit the signs peculiar to splanchnic neurasthenia 
(page 123), 

Tue Diaenosis or Iytestrnat Avto-[ytoxication.— 
From what has preceded, it is evident to the physician 
that the diagnosis of this affection is essentially object- 
ive. One can never place any dependence on an 
intuitive diagnosis; on the contrary, there is no affec- 
tion which demands a more thorough and exhaustive 
analysis. 

Despite the tedium of the examination, every neur- 
asthenic should be investigated with the object of 
determining whether auto-intoxication is responsible 
for his symptoms and even though enterotoxins are 
not the essential cause, they may accentuate them. 

Unfortunately the precise methods of physiochem- 
ical examinations are not available for the practitioner, 


170 THE BLUES :—NEURASTHENIA. 


hence they will not be made the subject of discussion. 
Such methods are accurately described in the recent 
classical treatise of Combe. * 

Tur Urtne.—The kidneys are the chief excretory 
organs for the enterotoxins arising from intestinal 
putrefaction and which have passed into the blood, 
hence an examination of the urine is an important 
procedure in the investigation of a suspected case of 
auto-intoxication. 

As arule the quantity of urine in 24 hours is dim- 
inished (oliguria) but despite this reduction of volume, 
its concentration is not augmented and its coloration 
is rather reduced. The specific gravity is usually be- 
low the normal and the excretion of urinary solids is gen- 
erally diminished. We know that asa result of microbic 
action aromatic substances (indol, phenol and skatol) 
are disengaged in the intestines and that they are ex- 
ceedingly toxic, but owing to their conversion into 
ethereal sulphates they are made innocuous. 

Ptomains are likewise disengaged in intestinal pu- 
trefaction and were weable to estimate these substances 
with any degree of accuracy in the urine, the entire 
question of auto-intoxication would be reduced to a 
very simple problem. 

However, no reliable practical method exists for de- 
termining the ptomains, hence we must content our- 
selves with the estimation of the aromatic substances. 

The latter are probably not the real enterotoxins 
but they develop as the ptomains parallel to the inten- 
sity of the putrefactive process, hence their presence 
serves as an index for determining the degree of intes- 
tinal putrefaction. 


* LT Auto-Intoxication Intestinale. Paris, 1907. 


THE CAUSE -AND CURE. iba! 


The aromatic substances (phenol, indol, etc.) unite 
with sulphuric acid and form the ethereal sulphates or 
with glycuronie acid. 

‘Tue Suripuates.—The sulphates in the urine are 
derived from the metabolism of proteids in the body 
and about one-tenth of the total sulphates are com- 
bined with organic radicles known as ethereal sulphates 
which originate from intestinal putrefactive processes. 
Sulphuric acid is found in the urine in two forms: 

1. As the inorganic or preformed sulphates in com- 
bination with sodium and potassium ; 

2. As the organic (ethereal or conjugate) sulphates 
In combination with indol, phenol, and skatol. 

The amount of the inorganic to the organic is as 10 
to 1 and in the norm the total excretion of both is 
from 30 to 45 grains. An increase in the excretion 
of the total sulphates occurs in augmented intestinal 
putrefaction. 

It is important not only to know the absolute 
amount of the ethereal sulphates in the urine but also 
to know the ratio which this amount bears to the in- 
organic sulphates. Indeed many investigators claim 
that this ratio is a better index of intestinal putrefac- 
tion than is the absolute quantity of ethereal sulphates 
excreted. As before remarked, this ratio in adults on 
a mixed diet is about 1:10 but in disease this ratio 
* may vary from 1:7 to 1:1. 

Tue Eruerran Surpuatres.—The only means of 
making accurate estimations of the sulphates is by 
weighing the Ba So,, but this is an elaborate process 
inapplicable to clinical work. 

The following is a simple test: Add an excess of 
barium chlorid to a urine previously rendered strongly 


172 THE BLUES :—NEURASTHENIA. 


acid with hydrochloric acid and a whitish precipitate 
of barium sulphate is formed, which is insoluble in 
acid. 

After allowing the urine to stand for several hours 
in the test-tube, the height of the precipitate will in- 
dicate approximately the quantity of ethereal sul- 
phates. The quantity of the precipitate compared 
with that from a normal urine will also afford a rough 
estimate of the sulphates present. The organic sul- 
phates are increased proportionally by the putrefactive 
decomposition of proteid in the alimentary canal. 
The ingestion of considerable quantities of meat will 
increase, and an exclusive milk diet will decrease the 
excretion of ethereal sulphates. 

InpicAan.—When albuminous substances undergo 
bacterial putrefaction in the intestine, aromatic sub- 
stances (indol, skatol and phenol) are formed. The 
demonstration of indol however may be accepted as 
representing the other substances. When the indol is 
absorbed it is oxidized forming indoxyl, and the latter 
unites with the preformed potassium sulphate to be- 
come potassium indoxyl-sulphate or, as it is generally 
called, indican. The equation representing this trans- 
formation is as follows: 


OH OC,H,N 


1 cs 
C.HNO+S0, <or=SO0, <~ Oe +H,0 
(Indoxyl) (Potassium (Potassium (Water). 
Hydrogen Indoxyl-sul- 
Sulphate) phate) 


Some contend that if indican can be detected in the 
urine, even by a feeble reaction, it is an indication 
that it is excreted in excessive quantity. Indican in 
the urine (indicanuria) suggests bacterial putrefaction 
of the proteid substances in the intestines, for in 


THE CAUSE AND CURE. 173 


perfect digestion of the proteids, it cannot be detected 
in the urine. Indicanuria also occurs when albuminous 
substances are decomposing in any part of the body as 
in the putrid pus of peritonitis or empyema. 

Trsts For Inproan.—(Jaffe). Free the urine of sub- 
stances interfering with the test by adding one-quarter 
its volume of 10 per cent. solution of lead acetate and 
then filtrating. To the filtrate add an equal amount 
of concentrated hydrochloric acid and one to two 
. drops of a saturated solution of calcium chlorid diluted 
one-half with water. If indican is present, first a 
bluish-green tint, later, a distinct blue color appears. 
If chloroform is now added and the whole thoroughly 
shaken, the layer of chloroform will turn blue and 
the depth of coloration indicates the quantity of in- 
dican. In a normal urine this test gives only a rose 
or faint violet color. Asa rule, unless the urine con- 
tains albumin or is very dark it is unnecessary to first 
precipitate with the lead solution. 

Test or OBERMAYER.—Obermayer’s reagent consists 
of a solution of strong hydrochloric acid (sp. gr. 1.19) 
to which has been added two parts to the thousand of 
ferric chlorid. This fuming yellow liquid keeps indef- 
initely. First precipitate the urine with a small 
amount of a solution of lead acetate (avoiding an ex- 
cess) and filter. Now take 15 cc. of the filtered urine 
and mix with an equal bulk of Obermayer’s reagent 
and add 2 cc. of chloroform. Slowly invert, but do 
not shake the mixture in the tube, which is sealed 
with the finger or acork. This chloroform will be- 
come colored in proportion to the amount of indican 
present. It may be necessary to allow the whole to 
stand for a short time for the complete oxidation of 


174 THE BLUES :—NEURASTHENIA. 


the indoxyl by the ferric chlorid. Normal urine gives 
a very faint blue by this method and any increase is 
indicated by a deep blue tint in the chloroform. 

The quantitative estimation of indican in the Ober- 
mayer test may be made by comparing the chloroform 
solution with solutions of pure indigo-blue in chloro- 
form of known percentage; other methods are the 
chromometer of Amann or the indicanurometer of 
Bouma. For all practical purposes, the simple test 
of Jaffe will suffice. * 

Ileratic Iysurricrency.—It has already been re- 
marked, that the liver is the chief organ of defense 
and insufficiency of this organ is among the chief 
causes of auto-intoxication, hence the diagnosis of the 
functional capacity of the liver is indicated. The 
diagnosis of hepatic insufficiency is based on the 
diminished excretion of urea and the presence of ab- 
normal constituents in the urine. 

Hypoazoturta.—Brouardel and other French clini- 
cians have long regarded a deficient excretion of urea 
as an important symptom of hepatic insufficiency, for it 
is generally admitted that urea is formed in the liver. 
Before concluding, however, that the urea is dimin- 
ished, one must first establish the fact, that the patient 
is ingesting a sufficient quantity of food. A manina 
state of nitrogenous equilibrium taking 100 grams of 
proteid in his food daily will excrete daily about 33 to 
35 grams (500 grains) of urea. If a patient according 
to Hirschfeld ingests during one day a test diet of 500 
grams of meat, 8 eggs, and 200 grams of bread, which 
represents a total of 172.25 grams of proteid, he will 
normally excrete 59 grams of urea. The normal per- 


* Vide, Porter’s test, preface to third edition. 


THE CAUSE AND CURE. 175 


centage of urea in human urine is about 2 per cent. 
One must also remember before concluding that the 
liver is insufficient, that, in addition to a diminished 
excretion of urea (hypoazoturia), there must be an 
augmentation in the urine, of ammonia, uric acid and 
purin bodies and the presence of leucin and tyrosin, 
insomuch as these substances are converted into urea 
by the liver. 

EsTIMATION OF THE Sortps.—A. simple and rapid 
method for determining approximately the total urinary 
solids excreted in 24 hours in 1000 parts of urine is to 
multiply the last two figures of the specific gravity by 
2. Thus, 1500 cc. of urine excreted in 24 hours with 
asp. gr. of 1017=2x17=34 grams in 1000 cc.: in 
1500cc. =34+17=51 grams. About 50 grams of 
solid matter is excreted in 24 hours: one-half of this 
consists of urea and one-fourth of sodium chlorid. 

Another simple method is to measure the total 
quantity of urine excreted in 24 hours in ounces: mul- 
tiply the number of ounces by the last two figures of 
the specific gravity and add to the product one-tenth 
of itself. Thus, if 50 ounces of urine were passed and 
the sp. gr. 1s 1020, the calculation is as follows: 
50 20=1000. Adding one-tenth of 1000=100 and 
1000+100=1100, the number of grains of solid matter 
excreted. The latter number of grains is normal for 
a person weighing about 135 pounds. Persons weigh- 
ing more or less should excrete relatively more or less 
solids. Urea may be determined quantitatively by 
Hind’s modification of the Doremus ureometer. 

CuotemiA. ‘This condition is provoked by the ab- 
sorption of bilirubin, which should have been elimi- 
nated into the intestine with the bile. Two-thirds of 


176 THE BLUES :—NEURASTHENIA. 


the toxicity of the bile is supposed to be due to bili- 
rubin. In the average patient, hepatic insufficiency is 
the underlying cause of cholemia. 

The skin may be yellowish in hue and is usually 
known as the ‘ billous complexion.’?’ The nervous 
symptoms are not unlike those of neurasthenia, to 
which mental symptoms are added varying from de- 
spondency to delusional melancholia. The liver is 
practically painful on pressure and even minor grades 
of sensitiveness may be determined by concussional 
massage (vide appendix; note 14). Examination of 
the urine for bilirubin in cholemia is usually without 
result, although the following method of examination 
of the blood is usually positive: about 3 cc. of blood 
from the punctured finger is allowed to drop into a 
dry, clean vessel, which is put aside without shaking 
in a cool place for 24 hours. The serum is drawn off 
from the clot and Gmelin’s test * is used. Just above 
the point of contact of the acid a bluish ring appears. 
Even in normal serum, according to Hayem, the reac- 
tion to bilirubin is positive in dilutions of 1 to 40,000; 
if the serum, however, is diluted with two-thirds 
normal salt solution and a positive reaction is obtained, 
the diagnosis of cholemia is assured. 

Puysrotoaic Trsrs.-—A well-known function of the 
liver is to form glycogen from the saccharine and 
amyloid mattersin the food. It has been demonstrated, 
that if the glycogenic function of the liver is impaired 
its antitoxic functions are equally implicated. 

According to Achard, the patient is given 150 


* In Gmelin’s test, crude yellow nitric acid is used or pure nitric 
acid may be employed, if it is first heated with some organic sub- 
stance like bits of wood, 


THE CAUSE AND CURR. 177 


grams of glucose; if sugar is found in the urine it 
indicates hepatic insufficiency. 

According to Naunyn, 100 grams of glucose given in 
solution two hours after a breakfast of a roll and 
butter with coffee will not cause glycosuria; if it 
does, the glycogenic function of the liver is implicated. 
According to the same author, if glycosuria follows 
« the dose cited, the individual may eventually suffer 
from true diabetes. 

Chiadini gives 50 grams of levulose, fasting, and if 
the liver is intact no glycosuria will follow, but levu- 
losuria will be observed in case of pathologic conditions 
in the liver. 

Chauffard attaches much importance to the inter- 
mittent excretion in the urine of methylen blue when 
this substance is used as a test. One may execute the 
test by an intramuscular injection of a 5% solution of 
methylen blue and the dose is 15 minims. It is ab- 
sorbed into the blood from the point of injection as a 
colorless derivative known as chromogen and it is 
transformed by the liver and kidneys into methylen 
blue. It is excreted in the bile and urine. In the 
urine it is eliminated as methylen blue and partly asa 
colorless derivative (chromogen). The latter is trans- 
formed into methylen blue by boiling with acetic acid. 
Chromogen commences to appear in the urine 15 
minutes after the injection and the blue in about 
80 minutes. The duration of elimination is from 35 
to 60 hours. The elimination of blue reaches its 
maximum about 4 hours after the injection and remains 
at this level for about 44 hours and after about 35 
hours, it assumes a pale green tint. 

In hepatic insufficiency, the elimination is inter- 

12 


178 THE BLUES :—NEURASTHENIA. 


mittent; it falls to the vanishing point to rise again 
or it may disappear completely ‘from the urine and 
reappear later. 

The greater the number of intone the more 
pronounced is the functional disturbance of the hepatic 
cells. 

To execute this test, the urine must be collected in 
different receptacles every two hours. 

Froat Examination.—No physician dare aim at ac- 
curacy in the diagnosis of intestinal auto-intoxication 
without an examination of the function of the intestine 
and this procedure has been so simplified by Schmidt* 
that I will not go into the details of his method. One 
may briefly refer to a simple method for determining 
the presence of urobilin in the feces. About 10 grams 
of the stools are rubbed in a mortar with a concen- 
trated mercuric chlorid solution and allowed to stand 
from 6 to 24 hours. 

Urobilin will be colored red while bilirubin con- 
verted into biliverdin imparts to the mass a green 
color. Both substances indicate that the liver is func- 
tionally active and that the biliary passages are open. 
The microscope will show the green tint of bilirubin, 
which may not be evident macroscopically because the 
color is obscured by the large amount of urobilin. 

TREATMENT OF InrestinaL Avtro-[yroxtcatTion.—A 
variety of methods have been suggested in the treat- 
ment of this affection and the writer has discussed some 
of them in detail in his work on auto-intoxication. + 


* Test Diet in Intestinal Diseases. F. A. Davis Co., 1906. 
Translated by Aaron. 

+ Man and His Poisons, Abrams. E. B, Treat and Co., New 
York, 1906, 


THE CAUSE AND CURE. 179 


Intestinal putrefaction results from the action of 
proteolytic bacilli on albuminous food and the primary 
indication in treatment is to modify the culture medium 
of the intestine so as to render it inimical to the organ- 
isms in question. The best and the most certain method 
of treatment is by means of an antiputrid régime. 

It has been suggested that a sterile régime will 
destroy the virulence of the bacterial flora of the 
intestine, but observations show that sterile food will 
diminish but does not completely inhibit intestinal 
putrefaction. 

An aseptic régime is best attained by the avoidance 
of crude vegetables and fruits, for no matter how 
thoroughly they are washed they still remain contam- 
inated. 

The cooking of foods will diminish the danger of in- 
fection by destroying bacterial growths and larger 
parasites (tapeworms and trichine). The cooking of 
vegetable foods breaks up the starch-grains, bursting 
the cellulose and thus permitting the digestive fluids to 
come into immediate contact with the granulose. 

Antieutrip Rteimme.-—As before remarked, this is 
the most satisfactory means of antagonizing intestinal 
putrefaction. The putrescent aliments are the proteids 
and if the latter could be completely eliminated, there 
would be no putrefaction and consequently no intes- 
tinal auto-intoxication. All investigations show that 
intestinal putrefaction augments parallel with the 
quantity of albuminous food-stuffs. We know, how- 
ever, that the proteids or albuminous food-stuffs are 
true tissue builders and repairers and consequently 
cannot be eliminated without compromising nutrition. 
We do know, however, that the proteid requirements 


180 THE BLUES :—NEURASTHENIA. 


of the individual have been exaggerated and that the 
experiments of Professor Chittenden show, that men 
can maintain health and muscular efficiency for long 
periods on about half the amount of proteid which is ~ 
usually consumed. It would be difficult now to main- 
tain, as did Herbert Spencer, that the consumers of 
meat showed superior physical strength to the con- 
sumers of rice, which would be equivalent to saying 
that the Russians demonstrated more physical endur- 
ance than the Japanese. One may conclude conserva- 
tively, that we ordinarily consume more proteid food 
than is necessary and that ingested in excess, it is 
either conserved for future uses of the economy or re- 
maining undigested, it must be reduced by bacterial 
digestion. Instead of the individual requiring 120 
grams daily of proteid according to the diet table of 
Moleschott or 100 grams according to the diet of 
Ranke, the amount of proteid may be reduced con- 
siderably without prejudice to the individual. 

If an individual were desirous of taking his daily 
supply (100 grams) of proteid in the form of meat it 
would be necessary for him to consume a little more 
than one pound (500 grams) of meat. It was at one 
time supposed that fats exercised no influence on intes- 
tinal putrefaction, but more recent experiments have 
demonstrated that this observation is faulty and that 
fats do increase intestinal putrefaction. 

The lacto-farinaceous diet of Combe is the anti- 
putrid régime par excellence in the treatment of auto- 
intestinal intoxication: it acts not by any destructive 
influence on the intestinal flora but seeks only to modify 
the soil in which the microbes live. 

Mirx.—Of all aliments, milk is probably the most 


THE CAUSE AND CURE. 181 


resistant to putrefaction and it has been found by 
Winternitz that if a certain quantity of milk is given 
with ameat diet, it will diminish the production of 
enterotoxins. Milk owes its antiputrid properties to 
the dactose which it contains and which under the in- 
fluence of the aerobic baccili of the small intestine 
(coli and lactis aerogenes) is decomposed into succinic 
and lactic acids. These acids inhibit the action of the 
proteolytic baccili in the large intestine from acting on 
the albuminous food-stuffs. Cow’s milk contains about 
3.5 per cent. of proteids (chiefly caseinogen) against 
12.2 per cent. in the white of eggs and about 20 per 
cent, in meats. 

I find that some individuals cannot tolerate even 
small quantities of milk (raw or boiled) without causing 
diarrhea. In such instances, I employ dactose (milk- 
sugar). Cow’s milk contains 5 per cent. of lactose, 
hence if the individual will take about 400 grains of 
lactose at each meal, he will have consumed an amount 
equal to about 3 pints of milk daily. Very often raw 
milk is tolerated when boiled milk is not. 

It has also been proposed to substitute milk by a 
number of aliments which already contain lactic and 
succinic acids and many of them are more digestible 
than the ordinary cow’s milk. They are as follows: 
Curdled milk. 

Whey. 

Buttermilk. 

Koumiss. 

Kefir. 

Fresh cheese (fromage ala creme). 

Buttermilk owing to its small content of fat and 
casein (chief proteid of milk) is a very desirable pro- 


Pee come ae ss 


182 THE BLUES :—NEURASTHENIA. 


duct in auto-intoxication, Insomuch as one knows that 
these substances favor putrefaction. Again, the pres- 
ence of lactic acid and lactose enables the latter to 
produce lactic acid ¢n statu nascenti. Condensed butter- 
milk may be obtained in flasks containing 330 grams, 
and to prepare the buttermilk, one mixes the contents 
of one flask with 660 grams of a decoction of cereals 
thus obtaining 1 liter of porridge ( potage aw babeurre). 

The composition of /fowmiss varies with its age, 
containing on the first day about .96 per cent. of 
lactic acid and about 1 per cent. on the 21st day after 
its preparation. It contains nearly the same percent- 
age of alcohol as beer. Koumiss is an agreeable and 
easily digestible preparation. 

Fresh soft cheese contains considerable assimilable 
casein and therefore subserves a useful purpose in pro- 
teid nutrition and it has all the advantages and none 
of the disadvantages of milk. Thus the soft cheese 
known as petit suisse contains the following: albumin, 
4 per cent.; casein, 24 per cent.; lactose, 2 per cent. ; 
and lactic acid, .60 per cent. 

Farinaceous AttmENnts.—Combe formulates the fol- 
lowing conclusions: 

1. The carbohydrates or sugary foods prevent pro- 
teid putrefaction in the intestine. 

2. That in natural digestion, the farinaceous foods 
(rice, farina of cereals and their derivatives) surpass 
all other carbohydrates because they are less easily 
absorbed and they penetrate more profoundly into the 
intestine and only gradually furnish lactic and succinic 
acids. 

3. That the maximum quantity of farinaceous food 
must be given withseach repast and, if possible, to 


THE CAUSE AND CURE. 183 


carry out this cramming process, this farinaceous 
aliment must be given five or six times a day. 

4. Interdict as far as possible all albuminous food- 
stuffs but choose among them the least putrescent (like 
egos) and when they are used, combat their action by 
an excess of farinaceous food. 

5. In the ordinary forms of auto-intoxication, milk 
mixed with farinaceous food is better supported than 
milk alone. 

6. Avoid fats which augment putrefaction and 
choose butter in preference. 

If one is desirous of carrying out, if only for test 
purposes, an antiputrid régime, one may select the 
following: | 
Milk or lactose‘as a substitute. 

Cooked vegetables preferably as purées. 
Preserved or cooked fruits. 

Weak coffee, tea or cocoa. 

Toast with little butter. 

. Farinaceous foods prepared as puddings, or other- 
wise. These must be consumed in abundance. 

7. Buttermilk or Koumiss. 

8. Fresh cream cheese. 

Later, if the condition of the patient is ameliorated, 
easily digestible albuminous food-stuffs like eggs, ham 
and cold meat together with fresh fruits (preferably 

bananas) may be permitted. 

Awnragonistic Microprs.—Ever since Metchnikoff 
directed attention to the fact that sour milk microbes 
are antagonistic to the microbes of putrefaction, it is 
quite the custom in France to employ the former in 
the treatment of auto-intoxication. The chief charac- 
teristic of the intestinal flora of the auto-intoxicated is 


Shae ar peed ee 


184 THE BLUES :—NEURASTHENIA. 


the marked diminution of the saccharolytic aerobic 
baccilli and the preponderance of the proteolytic 
anaerobic varieties. To modify the foregoing’ condi- 
tion a vegetarian or lacto-vegetarian or lacto-farina- 
ceous diet is Indicated on account of the small quantity 
of proteid matter which it contains and the lactic acid 
which it produces. Another method is to feed the 
subject with lactic acid ferments or microbes which 
are innocuous but exert an inhibitory influence on the ' 
microbes of putrefaction. There are now several lactic 
acid culture mediums on the market but many of them 
seem to lose their therapeutic action when prepared 
in the form of tablets or globules. 

Unquestionably, the liquid lactobacilline, as it is 
called, is the most efficient. It may be taken in milk 
or water directly from the small bottles in which it is 
sold and one bottle (containing about half a teaspoonful) 
a day is the average dose. During the first few days, 
digestive disorders may follow its use but soon consti- 
pation ceases, the stools lose their putrid odor, the 
breath sweetens and the tongue becomes cleaner. The 
signs of auto-intoxication disappear slowly but surely. 
To make these good results permanent, the treatment 
is continued on an average for 21 months. The fer- 
ment is ordinarily employed in association with the 
diet although some writers claim that nearly all the 
effects can be secured from the ferment alone. Accord- 
ing to Cohendy, it takes about six days before the 
lactic acid microbes change the intestinal flora. If 
diarrhea is caused by intestinal putrefaction, it is said 
to be arrested by this bacterio-therapeutic method. 

If lactic acid culture mediums cannot be obtained 
then buttermilk or koumiss may be used, Holt sug- 


THE CAUSE AND CURE. 185 


gests the following formula for the domestic manufac- 
ture of koumiss: one quart of fresh milk, } oz. of 
sugar, 2 oz. of water and afresh piece of yeast cake 
3 inch square) are put in wired bottles and kept at a 
temperature between 60 and 70°F. for one week: the 
bottles are shaken 5 or 6 times a day. They are then 
put upon the ice and kept ready for use. 

This bacterio-therapeutic method may have to be 
employed to the exclusion of the lacto-farinaceous diet 
. for there are some individuals who suffer from dys- 
peptic symptomsif the latter is pursued too vigorously. 
My personal observations show, that the diet is more 
reliable than all other methods of treatment. 

InrestrnaL Antiseptics.—Intestinal ascepticization 
is In my experience a purely theoretic conception which 
is rarely realized in practice. Intestinal antisepsis is 
difficult if not impossible for the following reasons: 

1. An antiseptic strong enough to destroy germs is 
equally destructive to the intestinal mucous membrane. 

2. Germicides will destroy the innocent germs 
which are concerned in digestion. 

3. Germicides are rapidly absorbed or are made 
chemically inert. 

Calomel is without doubt the most efficient of all 
intestinal antiseptics and it may act by inhibiting the 
growth of the microbes and preventing the formation 
of toxins. 

I have already expressed myself (page 158) concern- 
ing the action of purgatives. I may be permitted to 
say, in addition thereto, that purgatives often intensify 
the symptoms of auto-intoxication. They remove the 
intestinal epithelium and mucus which practically act 
as barriers against the absorption of eaterotoxins. We 


186 THE BLUES :—NEURASTHENIA. 


have discarded the swab in infectious diseases of the 
throat for the reason, that it mechanically injures the 
membrane of the throat and thus opens up new portals 
of infection. In this sense the purgative is essentially 
an intestinal swab. It not infrequently occurs that 
purgation will intensify the symptoms of auto-intoxica- 
tion on account of concentration of the poisons which 

have already been absorbed into the blood. Now, it 
is customary for some physicians to conclude, that, 
because the patient has a daily movement, there can 
be no intestinal auto-intoxication. Contrary to cur- 
rent opinion, I have found that in those suffering from 
self-poisoning, diarrhea, or at any rate, looseness of 
the bowels, prevails rather than constipation; it would 
appear that this is nature’s method of ridding the 
organism of noxious products. Strassburger has shown 
that retarded bowel-action, rather indicates diminished 
decomposition-products which normally stimulate in- 
testinal action. The odor of the feces often serves as 
an index to the grade of intestinal putrefaction. 
Healthy excreta are free from odor. 

Tue Sinusorpat Current. (Note 16, Appendix).— 
The application of this current to the abdomen (each 
sitting lasting from 15 minutes to one hour) is a valu- 
able method of treatment which I have employed for 
several years. It is especially applicable in cases of 
auto-intoxication caused by splanchnic congestion. It 
strengthens the abdominal muscles, relieves intra- 
abdominal congestion and hypereesthesia and promotes 
the absorption and excretion of enterotoxins. Washing 
the colon is an excellent method of treatment for acute 
cases of auto-intoxication but 1 would not recommend 
it as a routine method of treatment for the same 


= 


THE CAUSE AND CURE. 187 


reasons. that I discountenanced the employment of 
purgatives. Naturally in this, like in other diseases, 
one must endeavor to improve the general health, for 
everything that benefits the latter, will promote re- 
covery from the particular disease on the broad prin- 
ciple, that all that influences health equally influences 


* disease. 


Breap. AND Fruir Direr.—The Tlaig theory may 
be faulty but one is compelled to recognize this partic- 


‘ular diet which he recommends in certain high-blood 
_ pressure groups of intoxications, expressed as headache, 


epilepsy, depression, etc. In such instances, the fol- 
lowing diet is at least worthy of a trial. Roughly 
speaking, an individual weighing 140 pounds is required 
to consume 21 ounces of breadstuff a day, supplemented 
by 7 ounces of dry fruits. To this may be added a 
small quantity of potato or other vegetable, and any 
fresh fruit in season. The bread may be made as a 
pudding, using a little milk, but as far as possible 
fluids should be excluded. The foregoing day’s food 
may be divided into three meals each containing 7 
ounces of breadstuffs and 2 or 3 ounces of dry fruits. 
A blood-pressure of about 135 mm. can be reduced in a 
week or more to 120 mm. 


ay 





APPENDIX. 


NOTE 1.—PULMONARY ANEMIA AND INSUFFICIENT 
LUNG DEVELOPMENT.* 


Tue physiologic principles involved in respiration are 
not always strictly in accord with clinical observation. 
By this I mean that civilized man has so subverted 
primeval respiration, by attire and modes of living, that 
what is now regarded as physiologic, is really patho- 
logic. Physiology teaches that the lungs, even at the 
termination of expiration, are in a stretched condition, 
and the experiment is frequently cited of making an 
opening into the pleural cavity, which drives a certain 
amount of air into the trachea. Without entering fur- 
ther into a discussion of this matter, let us learn to what 
degree such physiologic teaching is in conflict with clin- 
ical evidence. The lungs do not by any means fully 
occupy the thoracic space. The costal and visceral lay- 
ers of the pleura make up a sac in which, so to speak, 
the lungs are let in. In certain thoracic situations the 
pleural sae is larger than the lung volume, and forms 
spaces, known as pleural or reserve spaces. Such spaces 
permit of changes in the lung volume, which otherwise 
would be impossible. The pleural spaces exist through- 
out the entire extent of the lung borders, the largest, 
known as the sinus phrenicocostalis, being located at the 
lower outer lung-border, at a point where the costal 
passes over into the diaphragmatic pleura. Figs, 5 


189 


190 THE BLUES :—NEURASTHENIA. 


and 6 show the sites of the pleural spaces (shaded) on 
the anterior and lateral aspects of the thorax. 

Even the deepest inspirations are not sufficient to 
cause the lungs to fully occupy the pleural spaces. The 
pleural space on the lateral aspect of the thorax may be 
filled, if the patient lies on the opposite side and con- 
ducts deep and forced inspirations. In quiet respira- 
tion, the difference in the position of the lower lung- 
borders during the respiratory phase is about 1 cm., 





Fig. 5. Showing pleural spaces shaded. (Eichhorst), Fig. 6. Pleural spaces 
(shaded) on the lateral surface of the left lung. (EKichhorst.) 
whereas, if the respiratory excursions are more pro- 
nounced, especially in the lateral chest region, the dif- 
ference may be as great as 13 em. This active mobility 
of the lung borders is always greater than the passive 
mobility, which is influenced by the body posture. Hay- 
ing succinctly reviewed these anatomic facts, we will 
now present the clinical findings, which contravene the 


* American Medicine, Feb. 15, 1902. 


THE CAUSE AND CURE, 191 


assumption of the physiologist, that the lungs are always 
in a stretched condition. I have frequently directed at- 
tention in the literature to constant areas of diminished 
lung resonance, varying from dulness to flatness, as ob- 
tained by percussion. In number and situation these 
areas vary, but they admit in the aggregate of definite 
localization. These areas of dulness, or atelectatic 
zones, as I have called them, possess one characteristic 
feature, they may be dispelled by repeated forced in- 
spirations. By this simple maneuver, resonance will 
supplant dulness. The atelectatic zones are dependent 





Fig. 7.—Patches on the front sur- Fig 8.—Patches onthe posterior 
face of chest. surface of chest. 

on circumscribed pulmonary atelectasis or collapse of 
limited portions of the lung, and dissociated with any 
demonstrable lesion. While it is true from the stand- 
point of the physiologist, that the lungs are in a_— 
stretched condition, it is equally true from the position 
of the clinician that certain portions of the lungs are 
collapsed and deprived of sufficient air to yield a dulness, 
and in some instances, a flatness on percussion. The 
atelectatic zones vary in size from a 25-cent piece to a 


192 THE BLUES —NEURASTHENIA. 


dollar, or even larger, and are permanently absent when 
the lungs are emphysematous, and temporarily so, after 
repeated deep inspirations, but they reappear in a few 
minutes, when tranquil breathing is resumed. In Figs. 
7 and 8 I have projected a composite picture defining 
the situation of the atelectatic zones, based on an exami- 
nation of over 100 apparently healthy persons, children 
as well as adults. On the posterior surface of the chest, 
the zones are more frequently encountered, and admit of 
more definite localization than those on the anterior sur- 
face of the thoracic wall. Since the advent of the 
Ktontgen rays, I have observed the following: (1) Ate- 
lectatie zones throw circumscribed shadows on the fluoro- 
scope, which will vary according to the degree and area 
of the pulmonary atelectasis. (2) The shadows cast 
by the atelectatic zones can be made to disappear by con- 
tinuous forced breathing, and they will reappear after 
a variable period when quiet breathing is resumed. (3) 
Before deciding whether the shadow cast on the fluoro- 
scope 1s really due to pulmonary consolidation, the sub- 
ject should be instructed to make forced inspirations; if 
the shadow disappears, and is supplanted by a bright re- 
flex, it 1s due to atelectasis; if the shadow persists, pul- 
monary consolidation may safely be concluded to exist, 
excluding, of course, other anatomic conditions that ~ 
would interfere with the transmission of the Rontgen 
rays to the finorescope. (4) Skiascopy of the lungs dem- 
onstrates that the opacities on the fluoroscope, corres- 
ponding to the atelectatie zones, greatly exceed the per- 
cussional areas of the latter, and, furthermore, that in 
individuals in whom no zones can be demonstrated by 
percussion, opacities are sometimes present, which dis- 
appear after forced inspiration. (5) Before and dur- 


THE CAUSE AND CURE, 193 


ing a radioscopie examination of the lungs it is always 
imperative to instruct the patient to practice forced 
breathing. 

What are the practical conclusions that may be formu- 
lated as a result of the foregoing observations? Danger 
may accrue from confounding the physical signs of ate- 
lectatie dulness with dulness caused by lung consolida- 
tion, an error which ean always be avoided, if the patient 
is directed to practice forced inspirations before pereus- 
sion of the chest is attempted. Whenever a localized 
dulness of the lung is detected, it is a wise provision 
to instruct the’ patient to take a series of deep breaths; 
if the dulness disappears, we are dealing with an ate- 
leetatic zone, if, however, the dulness persists, we are 
justified in concluding that there is some lung anomaly. 
I hold that topographic percussion, as obtained ordinar- 
ily, is of inconstant value. The limitation of organs by 
percussion, especially the heart, will vary from day to 
day, and the percussional area of dulness in the same 
ease and at the same time will be variously obtained 
by different diagnosticians. The borders of the liver, 
heart, and spleen are dependent on the degree of the 
lung inflation, and must vary according to the activity 
of respiration. Topographic percussion must always be 
based on the state of pulmonary inflation, and the results 
governed accordingly. The aid afforded by ausceulta- 
tion in the elimination of atelectasis is obvious. Aus- 
eultation of the lungs should be conducted with the 
patient in different postures, the object being to utilize 
the actual respiratory capacity of the lungs, thus elim- 
inating the auscultatory phenomena of atelectasis and 
accentuating abnormal sounds, which may be present. 
The recognition of the atelectatic zones is of the greatest 

13 


194 THE BLUES :—NEURASTHENIA. 
importance to the skiascopist, as failure to recognize 
them may lead to the grave error of misinterpreting the 
shadows cast on the fluoroscope as evidence of lung 
tuberculosis. Stubbert, in a contribution, maintains 
that he is unable to confirm my cbservations relative to 
the atelectatic zones. It is gratifying, however, for me 
to add, that Cabot, in his recent book, makes mention 
of my observations, and confirms them. Any physician 
who places sole reliance on percussion, or the shadows 
east on the fluoroscope, as evidence of lung consolida- 


tion, will commit the 
egregious blunder of 
interpreting tuber- 
culosis in more than 
50 per cent. of the 
patients coming to 
him forexamination. 

In Fig 3 ektewe 
observe the fluoros- 
cope reproduction of 
the lung apex Ina 
normal individual. 
Note the area 





Fig. 9.—A, c, Clavicle. 1. Area of apex in normal breathing. 2. Apical 
area in deep breathing. 3 Apical area after elicitation of lung reflex. B, 
Apical area after strapping the lower chest. 


of luminosity represented by the apex in tranquil breath- 
ing. (1) Observe how this area is augmented after 
forced deep breathing (2) and again after elicitation 
of the lung reflex (3). Observe the extraordinary in- 
crease in luminosity after strapping the lower chest 
which permits of breathing in the upper chest only (B). 
A word of.caution is necessary to those who are desirous 


THE CAUSE AND CURE, 195 


of confirming the latter observations. Owing to the 
extraordinary respiration in the upper chest area, the 
clavicles may obscure by their elevation, the luminous 
apical area, hence, the latter area should only be gauged 
when the patient practices forced expiration, which will 
cause a descent of the clavicles. 

I have already mentioned the fact that the atelectatic 
zones may be dissipated by forced inspirations, but this 
is not always true, for there are instances when only 
repeated forced inhalations of compressed air will cause 
their evanescence. There are two methods, which will 
cause their disappearance: by evoking the lung reflex,* 
which will be referred to later, and by change in the 
posture of the patient. The latter method I have only 
observed recently. I found that, when the patient bends 
forward for a few seconds, the zones ean no longer be 
elicited. This phenomenon I attribute to interference 
with the movements of the diaphragm, which evokes 
compensatory costal breathing. Not infrequently the 
lung apex in its entirety is atelectatic and this may even 
occur in a condition of apparent health. Kernig con- 
firms this observation, to which I have frequently re- 
ferred. Experience has taught me to regard most highly 
the observation originally referred to by Seitz, the value 
of percussing the upper borders of the lung apices, for 
the earliest evidence of tuberculosis. Both apices rise 
usually to the same height as determined by percus- 
sion, and the latter sign shows that the apices rise dur- 
ing inspiration and fall during expiration. Any differ- 
ence in the height of the apices or any retarded disloca- 
tion during the phases of respiration must always be 
regarded with grave suspicion. Figs. 10 and 11 show the 


* Appendix, Note, 9. 


196 THE BLUES :—NEURASTHENIA. 


normal height of the apices. Owing to the difficulty ex- 
perienced in the exact demarcation of the apices an- 
teriorly, I rely almost wholly on the evidence furnished 
on the posterior surface of the chest. 

Atelectasis bears an important relation to pulmonary 
tuberculosis and pulmonary anemia. In the former 
affection, the zones bear an almost definite relation to 
the points of election and paths of distribution of the 
lesions in chronie pulmonary tuberculosis. 

Putmonary Anemia. In children, less often in 





Fig. 10.—Extreme area of apleal Fig. 11.—Extreme area of apical 
resonance on anterior surface of the resonance on the posterior surface of 
chest. the chest. 


adults, an anemia is often associated with atelectatic 
zones. ‘This anemia I have designated as pulmonary. 
Pulmonary anemia attends multiplication or augmenta- 
tion in area of the zones. The syndrome of anemia dis- 
appears upon a course of methodic respiratory gymnas- 
tics, while its recrudescence is always associated with 
a reappearance of the atelectatic zones. Pulmonary 
anemia is not an invariable concomitant of lung atelect- 
asis, although as a rule, when anemia of pulmonary 
origin is present, atelectatic zones may be demonstrated. 


THE CAUSE AND CURE. 197 


In association with the anemia, fatigue on exertion, 
dyspnea, and heart palpitation, anomalies of digestion 
and constipation are usually present. Loss in weight 
is quite characteristic of pulmonary anemia, whereas, 
in the essential anemias, the well-nourished condition 
of the patient is manifest. There is another sign which 
distinguishes pulmonary from other forms of anemia, 
the one exception being, perhaps, progressive pernicious 
anemia, and that is, that while the ferruginous prepara- 
tion benefit pure anemics, in pulmonary anemia they 
are practically valueless, at any rate, the benefit accru- 
ing from their use is evanescent. The real pathogno- 
monic sign of pulmonary anemia is the therapeutic test. 
Subject such an individual to a single pneumatic cabinet 
treatment, employing inhalations of compressed air, and 
one invariably finds an increase in hemoglobin per- 
centage if the anemia is of pulmonary genesis. The 
qnantity of iron in pulmonary anemia is_ probably 
normal, the element lacking is oxygen, and this hypothe- 
sis is evidently correct, inasmuch as all pulmonary ane- 
mics were cured by breathing exercises only. The recog- 
nition of pulmonary anemia as one of the earliest trust- 
worthy signs of tuberculosis is of the greatest import- 
ance. I cannot adduce statistics in support of my con- 
tention, for that is a difficult matter. When, in the 18 
years of my practice, I encountered an instance of pul- 
monary anemia, the patient was treated and not sub- 
jected to scientific observation, so it is impossible for me 
to say how many of my untreated cases of pulmonary 
anemia would have terminated in bacillary tuberculosis. 
There are certain observations in medicine which must 
be purely empiric. J will instance a few observations 
which have some bearing on this subject: 


198 THE BLUES :—NEURASTHENIA. 


OsseRvaATIon 1. In a tuberculous family, of whom 
three members died of the disease, two daughters came 
to my office for examination. In one daughter atelectatic 
zones were variously distributed over the chest.. Hemo- 
globin reduced to 60 per cent. Usual subjective symp- 
toms of anemia. Treatment with the pneumatic cabi- 
net. <A period of five years has elapsed and the patient 
is still healthy. The other daughter also had the sub- 
jective symptoms of anemia, and the hemoglobin was re- 
duced to 70 per cent. Only one atelectatie zone was 
present, situated on the anterior surface of the chest 
close to the manubrium sterni on the left side, and 
about three inches in circumference. This patient un- 
derwent no treatment. Two years later she returned 
to my office with pronounced tuberculosis. Cavitation 
of the lung corresponding to the atelectatic zone pre- 
viously mentioned was evident. Six months later the 
patient died. 

OssrRvatTion ut. A young man, aged 16. Pro- 
nounced evidence of anemia. Atelectatic zones present. 
Treatment with the pneumatic cabinet of short duration. 
Three years later the patient died of tuberculosis. 

OBSERVATION Ir. Girl, aged 14. Hemoglobin re- 
duced to 50 per cent. Red corpuscles reduced to 70 
per cent. Atelectatic zones present. No other symp- 
toms. One year later patient presented herself with 
symptoms of pulmonary tuberculosis. Patient cured. 

The foregoing observations have been selected from 
a small number of analogous cases, and only justify the 
importance I have attached to pulmonary anemia as an 
early sign of tuberculosis. If pulmonary anemia is de- 
pendent on lung atelectasis, as I have attempted to 
show, the treatment indicated is lung development. All 


THE CAUSE AND CURE. 199 


my patients showed immediate and permanent improve- 
ment after daily inhalations of compressed air. The 
color of the patients improved, the oxyhemoglobin and 
number of red corpuscles increased and the subjective 
signs of anemia disappeared. Whenever the organism 
is compelled to dispose of more oxygen it produces more 
oxygen carriers. If relapses occur, which were not in- 
frequent, they were attributed in the main to neglect 
- of lung gymnastics or a return to former modes of life. 


NOTE 2.—THE CARDIO-SPLANCHNIC PHENOMENON.* 


Many of the facts here recorded with reference to 
this phenomenon have appeared elsewhere in this work, 
but their importance will bear repetition. 

To my knowledge this is an heretofore undescribed 
phenomenon, as far as its clinical manifestation is con- 
cerned. The facts, however, up to the point of its clin- 
ical identification have been fully established by the 
physiologic investigations of others. These facts are 
identified with intra-abdominal tension, and the effects 
of such tension on the blood circulation. Before de- 
scribing the phenomenon in question, it will be apposite 
to succinctly review a few essential points on the sub- 
ject of intra-abdominal tension. The latter in the norm 
is greater than the pressure of the atmosphere, and its 
positive pressure is exerted on the viscera which in turn 
press on the abdominal parietes, causing them to bulge. 
Should a reverse condition of things prevail, the walls 
of the abdomen would become retracted. Positive 
intra-abdominal pressure is subject to two conditions, 
viz.: the atmosphere pressure upon the yielding abdom- 
inal walls and the vigor of contraction of the abdominal 
muscles. For this reason, intra-abdominal pressure is 


* American Journal of the Medical Sciences, 


200 


THE CAUSE AND: CURE. 901 


‘most pronounced in individuals with powerful muscles, 
and least evident in multiparous women with flaccid ab- 
dominal walls. Clinicians recognize the secondary ef- 
fects of low intra-abdominal tension in conducing to 
splanchnoptosis, for, when the abdominal walls are re- 
laxed as a permanent condition, their pressure on the 
underlying structures is insufficient, and the result is a 
ptosis of the viscera. The effects of reduced intra-ab- 
dominal tension on the circulation has received but seant 
consideration from clinicians, a most lamentable fact, 
considering the gravity of the issue involved. Hill and 
Barnard have largely contributed to this important sub- 
ject, which has been practically elaborated in the ex- 
cellent work of Campbell. They have demonstrated that 
there is a tendency of the blood to accumulate in the 
splanchnic area, with consequent syncope. Like the gen- 
erality of veins, the great splanchnic veins are very sus- 
ceptible to pressure, and the amount of blood within 
them is greatly influenced by the pressure of the ab- 
dominal walls. Mere pressure of the abdominal walls 
suffices to squeeze out of them a large quantity of blood. 
Thus gravity, posture, the accoutrements of dress, and 
other factors greatly influence the amount of blood con- 
tained in the splanchnic area. More blood accumulates 
in the splanchnic veins in the erect than in the recumbent 
posture, and it is not an uncommon observation for syn- 
cope to occur in bedridden patients who are suddenly 
constrained to get out of bed. The removal of stays in 
women often induces a feeling of faintness, and the 
same symptom may occur when a large quantity of 
ascitic fluid is removed and in susceptible subjects when 
the bladder is emptied or feces discharged. This feeling 
of faintness or syncope, while present in the normal 


4 


202 - THE BLUES :—NEURASTHENIA. 


subject in the foregoing conditions, is greatly accentu- 
ated when the abdominal walls are flaccid. Three factors 
enter into consideration in the mechanism of blood sup- 
ply to the splanchnic vessels, viz.: 1. The contraction 
of the abdominal muscles; 2. The act of respiration, and, 
3. The regulating vasomotor action of the splanchnic 
vessels. The first factor 1s an important one, the trans- 
versales maintaining the anterior and posterior abdom- 
inal walls in fairly close contact and prevent in the erect 
posture the gravitation of blood in the splanchnic area. 
The second factor concerns the descent of the diaphragm 
and pulmonary suction. Every time the diaphragm de- 
scends, the intra-abdominal vessels are compressed, and 
the action thus exerted is less evident in the tense arteries 
than in the flaccid veins: the blood being squeezed out 
of the latter into the right heart. De Jager has shown 
that even strong pressure upon the abdomen has little 
or no effect on the arteries, but serves to squeeze a large 
quantity of blood from the splanchnic veins. Hill has 
also shown that, in consequence of some failure in cer- 
tain compensatory mechanisms, the blood gravitates into 
the splanchnic veins from the right heart, and that pres- 
sure upon the abdomen will send back the blood from 
these veins to the right heart, and thus re-establish the 
circulation. Such compression of the abdomen not only 
augments the input into the right heart, but it likewise 
increases, according to most writers, the systemic arter- 
ial pressure by increasing the peripheral resistance in 
the splanchnic area. 

Pulmonary suction refers to the large quantity of 
blood drawn into the lungs with each inspiration, and 
this physiologic process has not been inaptly compared 
to a species of dry cupping. Chapman avers “ that if, at 





Fig. 12.—Illustrating the cardio-splanchnic phenomenon. ‘The 
shaded area indicates the dull area obtained after vigorous com- 
pression of the abdomen. The contiguous area is the superficial 
area of cardiac dullness. 


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THE CAUSE AND CURE. 205 


the termination of expiration, the quantity of blood in 
the lungs is from 1-15 to 1-18 of the total quantity of 
blood in the body, at the termination of inspiration, it 
will be from 1-12 to 1-13.” The pulmonary vessels ex- 
pand with each inspiration, and contract during expira- 
tion, the result being an increased flow of blood from 
the right heart and the lungs: The dilated vessels, as 


Campbell puts it, “‘ actually sucks the blood out of the 


right heart. The final factor, the splanchnic vasomotor 
mechanism, in preventing the gravitation of blood into 
the splanchnic veins, is an important one. Hill and 
Barnard have demonstrated that the splanchnic vaso- 
motor mechanism suffices to combat this contingency, 
but when this mechanism is inhibited, as occurs when 
the splanchnic nerves are cut, a second mechanism is 
brought into prominence, viz.: Expiratory compressions 
of the abdomen occurring simultaneously with inspira- 
tory thoracic suctions, the former squeezing, and the 
latter sucking the blood out of the splanchnic pool. The 


latter mechanism compensates, however ineffectually, in 


" 


carrying out the circulation, and is referred to by Camp- 
bell as the ‘‘ respiratory mechanism.” That the latter 
mechanism is not as efficient as the vasomotor mechan- 
ism is evidenced by the fact that the effects of gravity 
may be entirely compensated for after the injection of 
eurare, which paralyzes the muscles. Both mechanisms 
may be inhibited by division of the spinal cord at the 
first dorsal vertebra, and if the animal operated on be 
held with the head up all the blood accumulates in the 
splanchnic veins, and the empty heart ceases to beat; 
if, however, the abdomen of the animal is compressed, 
the blood is expressed into the heart, and the circulation 
is restored. With the foregoing facts at our command, 


9206 THE BLUES :—NEURASTHENIA. 


we are in a position to appreciate what I have called the 
cardio-splanchnic phenomenon. 

If the lower sternal region, i. e., the part of the 
sternum contiguous to the heart, is first percussed in the 
standing and then again in the recumbent posture, one 
may note a decided alteration in the percussion tone; 
in the former attitude it is resonant or even hyperreso- 
nant, in the latter, it is dull or even flat. This is the 
eardio-splanchnic phenomenon. It may be elicited, but 
less pronouncedly when the patient is in bed and sits up. 
Vigorous compression of the abdomen will exaggerate 
the phenomenon in all instances. Not infrequently the 
deep or relative cardiac dulness will extend beyond the 
right border of the sternum. In no instance was this 
phenomenon absent, although hundreds of individuals 
were examined. It must be conceded that, in a few 
instances, the cardio-splanchniec phenomenon was only 
feebly expressed by mere attitudinal changes, yet re- 
enforcement of the maneuver by abdominal compression 
rendered its elicitation easy. A few forced inspira- 
tions will at once dispel the phenomenon, and it is like- 
wise dispelled by the application of a vacuum cup to the 
abdomen. If the liver and spleen are percussed first 
in the erect and then in the recumbent posture, a decided 
variation in regional percussion is obtained. In the 
former attitude, the area of dulness is increased, in the 
latter, it is decreased, and the splanchnic area of dulness 
may completely disappear. These conditions are super- 
added to the cardio-splanchnie phenomenon. Primarily, 
it is necessary to adjust the discrepancy of my observa- 
tions with those already accepted, and then to analyze 
the manifestations, which give genesis to the cardio- 
splanchnic phenomenon. Theoretically, one could at the 


THE CAUSE AND CURE. 207 


outset assume that the situs of the heart, more nearly 
approaches the anterior chest wall in the erect than in 
the recumbent posture, indeed it is not only assumed 
but accepted by clinicians, that in the latter posture the 
heart falls away from the thoracie wall. Even Kings- 
cote perpetrates a similar error by assuming that the 
preponderance of asthmatic seizures at night is caused 
_ by the recumbent posture, the dilated heart in this posi- 
tion causing it to impinge on the vagi. I have shown 
elsewhere the fallacy of this contention. By aid of the 
Rontgen rays, the triangular spaces in front and behind 
the heart are clearly defined, and the rays give undeni- 
able demonstration of the fact that change of posture 
only slightly modifies, if at all, the area of these spaces ; 
in fact, it may be observed in a number of instances, 
that when the patient assumes the recumbent posture, the 
anterior triangle is diminished and the posterior trian- 
gular space is increased in area, facts which contravene 
the contention that posture influences the relation of the 
heart to the chest wall. Again, percussional results are 
often influenced by the prejudicial preconceived ideas 
of the clinician. The skilled physician, in his interpret- 
ation of percussional phenomena, is guided not so much 
by the ear as by the tactus eruditus ; thus palpatory per- 
eussion will yield results which would wholly escape 
the observer, who is influenced only by what he hears, 
and not by what he feels. In the elicitation of the 
eardio-splanchnie phenomenon, palpatory percussion 
must be our chief mentor. Others may contend that 
my lung reflexes (the lung reflex of contraction and the 
lung reflex of dilatation) and the heart reflex may ac- 
count for the phenomenon in question, but all these 
Teflexes have been carefully eliminated, and play no role 


208 THE BLUES :—NEURASTHENIA. 


in the cardio-splanchnic phenomenon. It is true that 
in the recumbent posture the areas of splenic and hepatic 
dulness become decreased, and this in accordance with 
the well known fact that change of posture influences 
the position of the lung borders, the so-called passive 
mobility of the lung borders. In the recumbent, the 
lower lung border descends about $ inch lower than in 
the erect posture. The decrease in the areas of hepatic 
and splenic dulness as associated signs of the cardio- 
splanchnic phenomenon takes into consideration only 
the deep or relative hepatic dulness, together with 
the additional fact, that the areas in question are 
diminished to an extent not to be accounted for 
by mere passive mobility of the lung borders. The 
cardio-splanchnie phenomenon is easy of explana- 
tion. In the erect posture, the blood leaves the 
right heart, which topographically is underneath the 
lower sternum, and tends to accumulate in the splanch- 
nic area, whereas the recumbent posture opposes this 
influence of gravity. Pressure of the abdomen, which, 
in some instances must be vigorous, assists still further 
in expressing the blood from the splanchnic veins and 
sending it back to the heart. The same factors prevail 
with relation to the liver and the spleen, the amount of 
blood in the latter viscera being in direct proportion to 
the amount of blood contained in the splanchnic veins 
and in inverse proportion to the amount of blood con- 
tained in the heart. Forced inspirations hasten the out- 
put of blood from the heart, hence the almost immediate 
evanescence of the cardio-splanchnic phenomenon after 
vigorous breathing is executed. A word of caution is 
here necessary to those who seek the elicitation of the car- 
dio-splanchnie phenomenon. If the latter is provoked, in- 


THE CAUSE AND CURE. 209 


struct the patient to conduct only superficial breathing 
and not to wholly suspend it, otherwise, the blood will 
accumulate in the right heart from this very maneuver. 
The exhaustion of air by means of a vacuum cup applied 
to the abdominal surface will decrease intra-abdominal 
tension, and will consequently increase the quantity 
of blood in the splanchnic veins, and in this manner the 
right chambers of the heart will become depleted. I 
have endeavored, by means of the Rontgen rays, to de- 
termine whether any of the maneuvers already suggested 
for provoking the cardio-splanchnic phenomenon in any 
way influence the diameters of the heart, and my inves- 
tigations show that they do not. If the latter observation 
is correct, and there is every reason to believe that it 
is, how then can we account for the increased dulness 
of the lower sternum, the necessary concomitant of the 
eardio-splanchnic phenomenon. In the norm, the ster- 
num contiguous to the site of the right ventricle of the 
heart, yields pereussional resonance, which is caused in 
the main by the transmission of the percussion blow to 
the neighboring lung tissue. The percussion blow is 
propagated from 13 to 24 inches on the surface, and 
to a depth of about 24 inches. It is evident, then, that 
in the normal subject, the dulness of the right ventricle is 
not sufficiently pronounced to dampen the sound ob- 
tained from the vibration of air within the lung alveoli. 
It is, however, possible to conceive that if the right 
ventricle were sufficiently filled with blood, and this is 
eapable of fulfilment without any increase in the dimen- 
sions of the chamber in question, that the normally reso- 
nant sound of the lower sternal region could become dull 
or even flat. Our final endeavor is to show the value 


of the cardio-splanchnie phenomenon in diagnosis and 
14 


210 THE BLUES :—NEURASTHENIA. 


treatment. In estimating the size of the liver or spleen 
by percussion, we must pay due regard to the position 
of the patient, the amount of blood contained in the 
right heart and the vigor of respiration. The size of 
the liver is dependent in a measure on the amount of 
blood which it contains, and this has been estimated by 
Foster to be equivalent to one-fourth the amount of blood 
contained in the body. The skilled diagnostician will 
not find it a difficult task to demonstrate the reduction 
in the areas of hepatic and splenic dulness after repeated 
foreed inspirations. Such reduction cannot wholly be 
accounted for by the opening up of atelectatic lung areas, 
for, in the ease of the liver, pereussional results should 
refer only to the deep or relative hepatic dulness. Sup- 
posing the object of our examination is an enlarged liver 
or spleen, and we wish to determine how much of this 
enlargement is due to passive or active hyperemia, and 
how much to hyperplasia of the connective tissues ? 
Percussion in different attitudes, repeated forced in- 
spirations and abdominal compression will solve this 
question according to the methods previously advocated. 
If we wish to apply a crucial test, all that is necessary 
is to apply a vacuum cup to the abdomen, then in ac- 
cordance with the fact already established, the liver and 
spleen would become enlarged. Supposing a patient pre- 
sents himself complaining of pressure in the sternal re- 
gion, the nature of such pressure if due to an enlarged 
right heart may be easily determined by application 
of the vacuum cup to the abdomen; the blood will be 
expressed from the heart to the abdomen, and the sensa- 
tion of pressure will at once disappear. Let us further 
assume that we are confronted with an abdominal tumor 
and it is difficult to say whether such a growth is con- 


‘ 


> y THE CAUSE AND CURE. 211 


nected with the liver or the spleen, the application of the 
vacuum cup may solve the problem, for if the growth 
in question is connected with the liver or spleen, the 
latter viscera will show augmented dimensions, and con- 
versely their areas will be diminished by vigorous com- 
pressions of the abdomen. If the differential diagnosis 
rests between a pericardial exudate and a dilated heart, 
the elicitation of the cardio-splanchnic phenomenon 
would point to the existence of the latter condition. 
Idiopathic syncope and the vertiginous attacks of Glen- 
ard’s disease may be attributed to a defective splanchnic 
vasomotor mechanism. Now, in the average normal sub- 
ject the cardio-splanchnic phenomenon is fairly evident, 
but in the conditions just cited, it is exaggerated. In 
other words, the more perfect the mechanism, the less 
pronouneed is the phenomenon. There are a large num- 
ber of respiratory affections which owe their dyspnea to 
an overburdened right heart, and this is notably the 
ease in asthma. While I do not agree with Kingscote 
“that a dilated heart is the essential cause of asthma,” 
yet I do contend that an enlargement of that viscus is 
operative in predisposing to an asthmatic paroxysm and 
augmenting its severity. I have succeeded in arresting 
asthmatic paroxysms, which failed to yield to the con- 
ventional methods by the appheation of a vacuum cup 
to the abdomen. In these instances, suggestion probably 
played no role, insomuch as the relief of the paroxysm 
was coincident with the disappearance of the substernal 
dulness. It is unnecessary to adopt the theory of Kings- 
cote, that of a dilated heart striking the vagi, being re- 
sponsible for the asthmatic attack, the overburdened 
right ventricle being quite sufficient. Indeed, the pre- 
dominance of attacks occurring at night, as well as the 


912 THE BLUES :—NEURASTHENIA. 


dyspnea in cardio-respiratory affections, can be ex- 
plained by the augmented blood supply to the right ven- 
tricle, as the result of the recumbent posture. In my 
opinion, the upright position intuitively assumed in 
orthopnea is not only due to the fact that the extraordi- 
nary muscles of respiration may work to better advan- 
tage, but also for the additional reason that the blood 
from the right heart is enabled to gravitate to the 
splanchnic veins. 

Now in dyspnea from any cause, the implication of 
the heart in the production of this symptom may be 
gauged by expressing blood from the right heart by 
means of the vacuum cup to the abdomen. If the dysp- 
nea is relieved, we have reasonable assurance that it is 
caused by an overburdened heart. Instances could be 
multiplied, showing how the cardio-splanchnie phenom- 
enon may be employed in diagnosis, but the examples 
already cited will suffice. In treatment, the phenomenon 
suggests many possibilities in the direction of reestab- 
lishing the circulation and in relieving the heart when 
it is overtaxed. An accurate instrument for estimat- 
ing the blood pressure is a trustworthy guide in de- 
termining the value of any physical maneuver, which 
has for its object cardiac stimulation. An equally effi- 
eacious guide is the cardio-splanchniec phenomenon, not 
only the phenomenon per se, but the degree of its demon- 
stration. The precardial area of dulness is, as has al- 
ready been intimated, not dependent so much on the 
approximation of the heart to the anterior chest wall, 
but rather to the amount of blood contained in the ear- 
diae chambers. Inversion of the subject accentuates the 
eardio-splanchnic phenomenon and increases the dulness 
to the left of the lower sternal region, and diminishes it 


THE CAUSE AND CURE. 213 


over the latter area. In instances of syncope, it appears 
to me, that the object achieved is not so much the de- 
termination of blood to the anemic brain as it is to the 
determination of blood to the heart. I have sought to 
devise some apparatus whereby continuous compression 
of the abdomen may be effected in acute conditions de- 
manding cardiac stimulation. The simplest means for 
effecting this object is by means of a firm cushion ap- 
plied to the abdomen and secured by a rubber bandage 
or a broad strap, which permits of any degree of trac- 
tion. Not infrequently continuous pressure, such as is 
here described, gives rise to intereference with respira- 
tion, in which instance, one must content themselves 
with paroxysmal abdominal compression. 

The relief of an overtaxed right heart is suggested in 
so many cardio-respiratory troubles that it may be appo- 
site to select croupous pneumonia as a paradigm. There 
are so many indications and contradictions cited by 
writers for venesection in this affection that. it is really 
problematic whether bleeding is beneficial or harmful ; 
at any rate, its practice is purely empirical. It appears 
to me that in the general management of the average 
patient with pneumonia, the main object based on the- 
oretic grounds, would be to preserve the quantity of 
blood, for, after all, it is the chief stimulus for main- 
taining the cardio-pulmonary circulation and furnishes 
the leucocytes, which are such important factors in con- 
ducing to a favorable issue. Instances do occur with- 
out doubt, where bleeding is a justifiable procedure, 
but it would prove more effective if the patient could 
be bled into his own vessels. The application of a 
vacuum cup to the abdomen meets this emergency, and 
should ‘be employed, if only as a tentative measure, 


914 THE BLUES :—NEURASTHENIA. 


should an overburdened right ventricle with its con- 
secutive phenomena warrant its employment. If this 
maneuver is effective, it may be repeated, as it isa 
harmless and painless procedure. 


NOTE 8.—BLOOD PRESSURE. 


Arter vigorous compression of the abdomen and coin- 
cident with the development of the cardio-splanchnic phe- 
nomenon, my investigations show, contrary to the obser- 
~ vations of other clinicians, that the blood pressure falls. 
This is, in my mind, in accordance with two reasons: 1. 
By abdominal compression so much blood is suddenly ex- 
pressed into the right heart that the latter finds great dif- 
ficulty in discharging its contents; 2. Abdominal com- 
pression reflexly inhibits the heart action. Of the latter 
fact, I have convinced myself while executing the ma- 
neuver during the time the subjects were exposed to the 
X-rays. For this reason, in restoring cardiac action in 
syncope and other conditions, inversion of the patient or 
the application of a rubber bandage or leather belt 
around the abdomen, are safer procedures than abdomi- 
nal compression. The question of blood-pressure in neu- 
rasthenia has received ample consideration from investi- 
gators, but nothing, however, of a practical value has 
been definitely elicited. The instruments for gauging 
blood pressure are erroneous, and so are the deductions 
even with an instrument of recognized accuracy. I re- 
gard the Riva Rocci instrument as more serviceable than 
the tonometer of Girtner. The latter instrument is of 
little value on account of vasomotor changes in the finger 
of the patient, in hypertension and arterio-sclerosis. It 
is inapplicable in the negro. In hypertension and arte- 
rio-scerosis, clinical investigations have taught me aided 
by my stethophonometéer, which enables me to accur- 


215 


216 THE BLUES :—NEURASTHENIA. 


ately gauge the intensity of the heart sounds that un- 
reserved reliance placed on the tonometer as an instru- 
ment of precision in gauging blood pressure in arterio- 
sclerosis is unwarranted by clinical evidence. 

Arterio-sclerosis is by no means the general process 
which is taught. On the contrary, it may be central, 
peripheral or visceral. We may have a pronounced 
type of intestinal sclerosis without evidence of its ex- 
istence when gauged by the condition of the peripheral 
arteries. I recall a case of arterio-sclerosis of the coro- 
nary arteries of the heart which came to autopsy, the 
arteries in question being as rigid as the stem of a clay 
pipe, yet the individual during life showed no high 
pulse tension, no cord-like, resistant, tortuous nor ribbed 
radials; nor was there any evidence of heart hypertrophy 
or accentuation of the second aortic sound. 

It is usually taught that, when the tonometric figure 
is low with clinical evidence of arterio-sclerosis, it is a 
sign of failing heart power. The tonometer and other 
like apparatus are constructed on the general principle 
that, after the blood supply to a part is inhibited by 
compression, the gradual removal of the latter will re- 
lieve the obstruction and, when the point is attained at 
which the intra-arterial is greater than the extra-arterial, 
or capillary, pressure, it is indicated by a gauge which 
registers the blood pressure. Now, in arterio-sclerosis, 
even the smallest blood-vessels (arteriocapillary fibro- 
sis), are firm and unyielding, hence the compression 
of such vessels for gauging blood pressure conduces to 
erroneous results. I have frequently noted by the aid 
of the tonometer an apparent increase of blood pressure, 
notwithstanding the fact that cardiac auscultation nega- 
tived the existence of the same. Three factors make up 


THE CAUSE AND CURE. 217% 


the normal blood pressure, viz. : force of the ventricle, 
frictional resistance of the capillaries, and arterial elas- 
ticity. Lf the heart is weak, as is manifested by an en- 
Seebled second aortic tone, increased cardiac blood pres- 
sure cannot exist. I am, therefore, constrained to 
conclude that in gauging blood pressure reliance should 
only be placed on cardiac auscultation. 
It is generally conceded that of all the factors that 
make up blood pressure the resistance offered by the 
blood-vessels is one of the most important. 

If the vessels are dilated, the pressure falls; if con- 
tracted, it will rise. The nervous mechanism which 
controls the blood-vessels is the vasomotor apparatus, and 
while the latter I concede may be reflexly influenced by 
irritation from the blood-vessels themselves or from the 
end organs of sensory nerves in general, we are inclined 
to forget that the vasomotor apparatus may operate inde- 
pendent of such influences. Emotions and the state of 
the mind in general, greatly influence the caliber of the 
blood-vessels through the vasomotor system of nerves. 
Take neurasthenics as a paradigm, and I have examined 
a large number of them at different periods under emo- 
tional influences, intense mental application, and when 
their brains were at rest and in each instance my re- 
sults varied. Emotional influences and intellectual ac- 
tivity increased blood pressure, while mental inactivity 
reduced it. Again, increased cardiac pressure does not 
react equally on all the blood-vessels, and this, evidenced 
by the fact that the blood pressure in both radials is not 
always the same. Another factor influencing blood 
pressure is the heart volume, which is continually sub- 
ject to reflex conditions (see Heart Reflex, appendix, 
note 8). - 


NOTE 4.—THE STOMACH AND COLON ON THE POSITION 
OF THE HEART,* 


I nave referred elsewhere to the influence of a dilated 
stomach on the position of the heart. The accompanying 
illustrations show how easily the heart may be dislocated 
by artificial distension of the stomach. It is unnecessary 





Fia. 13.—1, radioscopic appearance of the heart before administration of a 
Seidlitz powder ; 2, outline of the fundus of the stomach. The shadow of 
the heart area as shown in this and in fig. 14, is only correct in reference to 
the parts contiguous to the sternum as this bone obscures the heart sil- 
houette. 


to descant on the practical value of this observation. 

Heart dislocation from stomach dilation is associated 

with a circumscribed area of dulness in the left inter- 
* Medical Record, Sept. 8, 1900. 
218 


THE CAUSE AND CURE. 919 


scapular region. Over this area, bronchial respiration is 
heard. When the patient leans forward, dulness and 
bronchial breathing disappear, to reappear when the 
erect attitude is resumed. (Figs. 15, 17, 18.) 

Leaning backward increases the area of dulness. The 
phenomena in question are produced by a dislocated 
heart compressing the lung, which fact is easily verified 


_ by the rays. 





Fie, 14.—1, radioscopic appearance of the heart after administration of the 
Seidlitz powder ; 2, outline of the fundus of the stomach, 


The foregoing syndrome may be reproduced synthet- 
ically by artificial distension of the stomach. An enor- 
mously distended heart may produce identical signs. 
Artificial insufflation of the colon is incapable of pro- 
ducing the same degree of cardiac luxation. 

These observations explain the heart distress and 
pains after eating and from gas accumulations in neu- 
rasthenia. 


NOTE 5.—PHYSICAL EXAMINATION OF THE LIVER. 





THe conventional methods of examining the liver are 

~by no means trustworthy. At the present time, palpa- 

tion and percussion of the liver are the methods which 
will alone claim our attention. 





Fig. 15 —Patch of dulness in dislocation of the heart upward; patient in 
the erect position. 


In palpating the liver, the physician proceeds exactly 
as if he were going to palpate hisown liver. The pa- 
tient should stand with body inclined very far forward, 
as shown in the illustration, then, with the fingers 
lightly bent, in a hook-like manner, they are insinuated 


220 


THE CAUSE AND CURE. 991 


; it will be found 
that, when the fingers are introduced under the ribs 
in the right mammary line, they can be made to pene- 
trate a considerable distance. The fingers being fixed, 
in this situation and immobile, the patient is instructed 
to take a deep breath and in accordance with the fact 
that the liver alternately rises and falls during breath- 
ing, the border approaches the fingers during inspiration 


well under the curvature of the ribs : 





Fig, 17,—Patch of dulness in dislocation of the heart, Same patient lean- 
ing backward. 


and recedes during expiration. This is my method of 
palpation, and I have rarely known it to prove unsatis- 
factory. (See Frontispiece. ) 

In Prroussion or THE Liver, we have first to deal 
with the topographic percussion of the upper and then 
the lower border of the organ. 

In Percussion or THE Urrer Borper, I have al- 


29 THE BLUES :—NEURASTHENIA. 


ready introduced to the profession a modified method of 
auscultatory percussion. 

The modified method of auscultatory percussion, 
which I here advocate, is suggested after several years’ 
experience in its employment. Its accuracy I have fre- 
quently controlled by skiascopy. It embodies the prin- 
ciple of transsonance. It is available in topographical 





Fig. 18.—Fluoroscopic picture in dislocation of the heart. Black areas, 
shadows cast by normal heart. Shaded area, shadow of dislocated heart. 
percussion, and for determining the density of the lungs 
after a method which will be presently described. Per- 
cussion transsonance is obtained when the thorax is per- 
cussed, either directly or indirectly, at a time contempo- 
raneous with auscultation at some remote point. In my 
modified method of auscultatory percussion, the clav- 
icles, sternum, ribs or vertebrae are percussed directly, 
i. e., without the interposition of the finger as a plexi- 
meter. The percussion-blow is either light or strong, ac- 


THE CAUSE AND CURE. 993 


cording to whether the superficial or deep dulness is to 
be elicited. If, for example, the area of cardiac dulness 
is to be obtained, the clavicle or manubrium sterni is 
pereussed directly, and the stethoscope is gradually car- 
ried towards the organ in all directions from the lung. 
The area of the heart is at once indicated by a dull tone 
supplanting a resonant one. <A similar procedure is 
earried out in eliciting the upper liver-border, and the 
splenic area of dulness. Lung-consolidation is also easy 
of elicitation by this method. If, for example, the trans- 
sonance of the apices is to be determined anteriorly, the 
stethoscope remains fixed first over one and then over 
the other apex, while immediate percussion is executed 
on a prominent vertebra. If the apices are to be auscul- 
tated posteriorly, the percussion-blow is limited to the 
manubrium sterni. It is possible by this method to out- 
line the right auricle and the left ventricle on the pos- 
terior chest-surface, provided the patient is in the erect 
posture with body inelmed slightly backward. The pec- 
toral chest-piece of the stethoscope should possess a small 
ealiber for the better object of demarcating the outline 
of organs. The fact must be emphasized that during the 
time this method of auscultatory percussion is executed 
the percussion-blow on some prominent bony structure 
must be continuous and uniform, while the stethoscope 
is carried toward the organ to be outlined. The percus- 
sion-hammer, recently designed by Dr. Heinrich Stern, 
of New York, will prove of great value in obtaining uni- 
form results. 

The drawbacks pertaining to my method are present 
only in corpulent individuals, in whom the well-padded, 
bony structures will not permit the percussion-blow to 
be conveyed to any distance. Another drawback, which 


994 THE BLUES :—NEURASTHENIA. 


is also present in the conventional auscultatory percus- 
sion is the inability to interpret the character of the per- 
cussion-sounds. This is, of course, a matter of practice. 
I cannot too highly extol this method, not only in topo- 
graphical percussion, but also in determining the reso- 
nating qualities of the pulmonary tissue. I have elicited 
incipient lung-consolidation when the conventional 
methods have failed. I have also used this method for 
outlining the lower border of the stomach. The method 
of procedure in determining the latter, is briefly as fol- 
lows: With the finger the lower ribs over the semilunar- 
shaped space of Traube are percussed, the stethoscope 
being fixed primarily in the hypochondrium in order to 
learn the character of the tympanitic tone. Then, while 
percussion is continued, the end of the stethoscope is 
gradually carried downward until the disappearance of 
the tone indicates that we have reached the lower border 
of the stomach. 

Percussion oF THE Lowrr Liver Borprer. The 
value of regional hepatic percussion needs no expatia- 
tion. No one, however skilled in percussion, can gain- 
say the insurmountable difficulties which beset the clin- 
ician in his attempts to demarcate an organ which is im- 
mersed in an atmosphere of tympanitic sound, and the 
edge of which does not exceed one centimeter in thick- 
ness. ‘Take into consideration the facts that the con- 
tiguous viscera, stomach and intestines, vary in their de- 
eree of inflation and in the character of their contents, 
and we have additional factors which modify the ac- 
curacy of our percussional results. Posture and the 
phases of respiration are likewise disturbing elements. 
A liver may be very much enlarged, yet percussion as 
ordinarily practiced may give absolutely no evidence of 





Fig. 19.—Author’s method or percussing the lower liver border. The 
illustration does not show sufficient inclination of the body backward. 


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THE CAUSE AND CURE. ype 


enlargement, if examination is made in the recumbent 
posture. A good rule to follow is never to declare the. 
liver to be enlarged unless it is palpable ; but palpation 
may detect a liver which is dislocated, though not neces- 
sarly enlarged; and, again, rigidity of the abdominal 
parietes may negative the value of palpation. 

Inmy “ Manual of Diagnosis,” I have referred to 
two methods of determining the lower border of the 
liver. One method is that described by C. Verstraelen, 
which is based on the fact that the intensity of the heart 
tones is well preserved over the entire hepatic region; at 
the lower border of the liver, however, the tones are 
suddenly lost; and in this way the lower liver border is 
determined. The abdominal walls must be relaxed, 
otherwise they will conduct the heart tones. This method 
I consider imperfect, as it is never of value if the car- 
diac tones are weak. Another method which I advo- 
eated in the same book is as follows: The patient is 
placed in a position favoring the approximation of the 
liver to the abdominal walls. This position is the knee- 
elbow one, or, if this is impossible, the erect posture, the 
body being inclined forward. ‘The edge of a large coin 
is then deeply embedded in the abdominal walls, and the 
free edge of the coin is percussed lightly and shifted 
eradually upward from the tympanitic area until dul- 
ness is elicited. If this dulness represents the liver bor- 
der, then, in accordance with the fact that the liver un- 
dergoes respiratory dislocation, the line of dulness will ° 
be lower during inspiration and higher during the act 
of expiration. The essential object embodied in this 
method is to verify the correctness of the percussion by 
dislocation of the organ during respiration. The latter 
method is relatively inaccurate, as I have had occasion 


998 THE BLUES :—NEURASTHENIA. 


to observe by controlling the percussional results by 
palpation in numerous instances where the latter method 
was easy of attainment. 

A simple maneuver for mapping out the lower liver 
border on the surface of the abdomen is as follows: The 
patient is instructed to incline his body backward as far 
as possible, and, to relieve the tedium of the posture, the 
body is supported by means of the hands resting on 
the hips. If percussion, which must be hght, is now at- 
tempted, the difficulty of determining the lower hepatic 
border is reduced toa minimum. (See Fig. 19). 

If we analyze the rationale of this maneuver we will 
find that it involves a simple law in physies, viz.: that 
sound waves are best conducted by the medium in which 
they are produced. If the waves of sound are compelled 
to pass through media of different density, some of the 
waves will be lost by reflection, and the sound becomes 
correspondingly enfeebled. Solid bodies conduct sound 
better than air. If percussion of the lower liver border 
is executed in the conventional manner, the percussion 
sound first passes through the relatively-dense abdominal 
musculature and then through the air containing viscera 
before it reaches the liver. Theoretically at least, the 
percussion sound becomes enfeebled by the time it 
reaches the liver, inasmuch in the high pitch which re- 
veals anything solid is dependent on the loudness of the 
pereussion note, which in turn depends on the force ex- 
erted in percussion. We dare not employ a strong per- 
cussion sound in mapping out the lower hepatic border, 
for, by so doing, we set in vibration the air contained 
in the neighboring viscera and defeat the original object 
of our percussion, viz.: the elicitation of a dull sound. 
In the posture suggested, we approximate the surface 


THE CAUSE AND CURE. 229 


of the liver to the abdominal parietes, thus affording a 
like medium for the transmission of the percussion 
sound. When patients are compelled to assume a recum- 
bent posture the same object may be achieved by direct- 
ing them forcibly to contract the abdominal muscles 
during the time percussion is executed. The results by 
the latter maneuver, however, are less accurate, though 
relatively better than by the conventional method of 
percussion. 

Percussion of the liver while the abdominal muscles 
are contracted is a valuable means of ascertaining sensi- 
tiveness of the liver. It is a better method than palpa- 
tion, which only admits of testing the sensitiveness of 
the lower border of the liver. J am cognizant of the 
dictum of Frerichs,. who directed attention to the fact 
that contraction of the abdominal muscles will fre- 
quently yield a dulness on percussion, which is likely to 
be confounded with the dulness of the liver. This objec- 
tion is, to my mind, purely theoretic. There is one 
condition, however, which demands consideration in per- 
cussion of the lower liver border and that is the presence 
of fecal concretions in the intestines contiguous to the 
liver border. The observation is undoubtedly correct 
that no one should rely on the results of liver percussion 
unless the bowels have been previously cleaned by free 
purgation. This teaching applies with all cogency to the 
entire abdomen. Experience has taught me the follow- 
ing simple method of determining the presence of fecal 
matter. If by palpation or percussion we suspect the 
existence of fecal stasis, massage of the suspected area 
for a few seconds will dissipate the dull percussion 
sound, which will then be supplanted by a tympanitic 
percussion tone. It is therefore imperative, before de- 


230 THE BLUES :—NEURASTHENIA. 


termining the lower border of the liver by the maneuver 
already suggested, to massage that region for several 
seconds. 

There are two additional facts which deserve mention: 
First, the patient must be cautioned to take no inspira- 
tion before contracting the abdominal muscles, for by 
so doing the liver will be dislocated downward; second, 
in practicing percussion, the finger receiving the per- 
cussion blow must be firmly embedded in the abdominal 
wall; otherwise, the blow will not be directly transmitted 
to the liver. 

After we have ascertained the lower liver border after 
the foregoing method, for corroborative purpose we may 
elicit the diver reflex. (See Appendix, Note 6.) 


NOTE 6.—THE LIVER REFLEX. 





_ Menrtton has already been made in this work of va- 

rious visceral reflexes to which I have first directed atten- 
tion. All these reflexes are of great clinical importance, 
and in a therapeutic sense serve to explain the beneficial 
action of electro and hydrotherapy as well as other pro- 
cedures applied to the skin for remedial purposes. The 
reflexes in question give objective demonstration how 
agents acting on the skin reflexly stimulate nutrition of 
the organs. 

The liver reflex, which is here referred to for the first 
time, is elicited by irritating the skin contiguous to the 
lower liver border. The irritant may be a spray of 
ether, scratching the skin with the finger nail, or the 
blunt end of a pencil. Subsequent to any of these 
maneuvers, the lower liver border may be observed by 
percussion to recede a half-inch or more, depending on 
the degree of irritation. The sinusoidal current acts 
more efficiently in this regard than any irritant in caus- 
ing the liver border to recede. This retraction of the 
lower liver border is dependent entirely on contractility 
of the liver itself, and not, as I have assured myself by 
repeated observations, by any influence on the amount 
of blood contained in the liver. I have already referred 
to the fact (see Appendix, Note 2), that the size of the 
liver can be graduated by the depth of respirations and 
compression of the abdominal wall. 

231 


232 THE BLUES :—NEURASTHENIA. 


The liver reflex is dependent on contraction of the 
muscular fibers contained in the fibrous coat of the liver 
which, as is known, invests the entire gland and at the 
transverse fissure, this coat turns into the substance of 
the liver with the branches of the portal vein. 


— ET 


NOTE 7.—THE CONDITIONS OF THE LUNGS ANTEDAT- 
ING PULMONARY TUBERCULOSIS; BREATHING EX- 
ERCISES FOR DEVELOPING SUCH LUNGS.* 


Tue early recognition of pulmonary tuberculosis gives 
promise of its successful treatment, for, if there is one 
fact which the phthisiologist has demonstrated for cura- 
tive medicine, it is the curability of phthisis. To-day the 
words of brehmer are verified: ‘* Tuberculosis primis in 
stadus semper curabilis.” The presence of shadows on 
the screen, as determined by the rays, is a sign equally as 
tardy as the recognition of tubercle bacilli in the sputa. 
We are here concerned only with skiascopic evidence, 
which betrays the disease at its very incipiency, even 
before physical signs are manifest. In this respect, the 
rays are of undoubted importance, and we possess a 
means which permits of the very earliest possible diag- 
nosis. Many of us, in our practice, meet with the 
phthisiophobiae, and we are now in the possession of 
means that will often rid that unfortunate individual 
of his fear. Of course, to depend on the rays alone for 
purposes of diagnosis would be to invite exclusivism, 
which would be fraught with danger to the catholic 
foundation on which diagnosis rests. There are two 
early signs to which I wish to direct attention, viz.: | 
restriction of the excursions of the diaphragm, and the 
emphysematous X-ray appearance of the lungs. The 
physiologic diaphragmatic excursions vary according to 
whether the breathing is quiet or forced. In quiet 

* American Medicine, March 1, 1902, and Journal of the Amer, 


Mvd. Assoc. 
233 


934 THE BLUES :—NEURASTHENIA. 


breathing, the extent of movement is about 1.8 em. on 
the right, and 1.5 em. on the left side; whereas, in forced 
breathing, the difference in the position of the dia- 
phragm between forced inspiration and expiration, aver- 
ages 6.7 cm. on the right and 7 cm. on the left side. In- 
dividuals with long thoraces show greater excursions of 
the midriff than deep-chested persons. The restricted 
diaphragmatic movements must be regarded as a very 
suspicious sign of phthisis, other things being equal. 
This sign, first referred to by Williams, of Boston, has 
received universal confirmation, but, to my knowledge, 
no theory has been advanced to explain its existence. I 
have sought elsewhere an explanation for this curious 
phenomenon, and I will briefly summarize my investiga- 
tions, which gave birth to the theory that an emphysema- 
tous condition of the lungs exists in phthisis. Rokitan- 
sky noted that too voluminous lungs coupled with a small 
heart characterized the phthisical habitus. No one 
seemed to have contradicted this observation, and as a re- 
sult it was soon relegated to oblivion. Brehmer revived 
and vigorously defended this hypothesis. The too volu- 
minous lungs of Rokitansky and Brehmer are lungs 
which are practically the lungs of emphysema. In 
health, the percussion note of the lungs is resonant dur- 
ing inspiration and dull or even flat during expiration. 
In emphysema, the percussion note is unchanged during 
the two phases of respiration. This unchanged percus- 
sion note heretofore recognized in pulmonary vesicular 
emphysema is pathognomonic of lungs predisposed to 
tuberculosis, and in lungs already affected. Associated 
with the unchanged percussion sound there is an exten- 
sion of the lung borders manifested by downward lung 
dislocation and diminution to the extent of obliteration 


THE CAUSE AND CURE. 935 


of the cardiac and splenic areas of absolute dulness and 
diaphragmatic immobilization. As a rule, this lung em- 
physema in phthisis is limited to the lower lobes and is 
dependent on the fact that the air entering the respira- 
tory tree travels in the direction of least resistance. Not 
infrequently, emphysema is associated with atelectatic 

zones. If physicians were to depend on percussional dul- 
ness as an evidence of early phthisis, the affection would 
never be recognized ; lung resonance, not dulness, is the 
early physical sign of phthisis. The rays are invaluabie 
in the recognition of the emphysematous condition. The 
lungs seem too large for the chest, the diaphragm is low 
and its excursions restricted. The lungs appear perma- 
nently bright, not alternately so as in their normal con- 
dition, and “ statuesque” is about the best word to de- 
scribe their appearance. It is interesting to observe 
parenthetically, how such lungs contribute to the devel- 
opment of phthisis. Defective pulmonary elasticity 
means some defect in the pulmonary elastic tissues. It 
may mean a congenital defect, as Cohnheim has ob- 
served, in a large number of cases of emphysema. A 
loss of pulmonary elasticity eliminates an important fac- 
tor, not only in lung nutrition, but in the nutrition of 
the entire organism. 

The exercises, then, in individuals with the phthisical 
lung, must be attempted not only in the direction of 
promoting inspiration, but what is even more important, ' 
in promoting the expiratory phase of respiration to expel 
the residual stagnant air in the lungs. The following 
simple method is serviceable: Two bottles, each capable 
of holding a gallon of water, are connected, as shown in 
the illustration. 

The patient is directed, by expiration only, to trans- 
fer the water from one bottle to another. After a little 


2936 THE BLUES :—NEURASTHENIA, 


practice, with a single forced expiration, this is possi- 
ble of achievement. I direct my patient to carry out 
this exercise, twice daily, each exercise lasting five 


minutes. 





Fig. 20.—Arrangement of bottles for expiratory exercises. 


The patient may also use with convenience and ad- 


vantage a spirometer for exercising expiration. 
This instrument will register the amount of air forced 


out of the lungs. The simplest and cheapest instru- 
ment for this purpose is the simplex spirometer. 


NOTE 8.—THE HEART REFLEX.* 


SomE years ago, I first directed attention to a phe- 
nomenon before undescribed, which I called the heart re- 
flex. At that time I ascribed to it little clinical value, re- 
garding it solely in the light of an interesting observa- 
tion. Since then I have devoted considerable attention 
to this reflex, with the object of ascertaining its practi- 
eal application. The result exceded my expectations. 
The heart reflex can be observed only with the Réntgen 
rays, the fluorescent screen approximating the anterior 
chest wall. The reflex is especially pronounced in chil- 
dren, and is best seen in adults with thoraces scantily 
furnished with musculature and panniculus. If we ir- 
ritate the skin in the precordial region by vigorous 
rubbing with a blunt instrument, a contraction of the 
myocardium is observed. The myocardial contraction 
is, as a rule, more manifest in the left than in the right 
ventricle. The contraction thus induced is not sudden 
and of momentary duration, as I described in my origi- 
nal paper; on the contrary, its duration in children, on 
whom most of my observations were made, is not less, as 
a rule, than two minutes, and furthermore the myocar- 
dial recession continues even after the source of cuta- 
neous irritation is removed. The degree of myocardial 
recession (heart reflex) varies greatly. In some persons 
it is scarcely perceptible, while in other individuals the 
heart may recede fully an inch on either side upon the 
first application of the cutaneous irritant. The accom- 
panying illustration (Fig. 21) shows the degree of 


* Medical Record, Jan. 5, 1901. 
237 


238 THE BLUES :—NEURASTHENIA. 


myocardial recession (line B) after cutaneous irrita- 
tion; A representing the normal outline of the heart 
drawn on the fluoroscope. 

This illustration is an exaggerated one, for, in the 
many examinations made by me, I have never been able 
to induce so marked a reflex. It is strange that in not 
a few instances the myocardial recession, although rarely 





ae thas 


~74.--- wowe--> 


Fig. 21.—Heart reflex in a boy aged eight years. Duration of reflex, two 
and a half minutes. 


absent when observed with a good X-ray apparatus, is 
but slightly marked. For this vagary, I am unable to 
account, occurring, as it does, in individuals with ap- 
parently healthy heart-muscle. 

In Fig. 22 we note a rough reproduction from the 
fluoroscopic picture, demonstrating slight myocardial 


THE CAUSE AND CURE. 239 


recession confined solely to the left ventricle; A, repre- 
senting the cardiac outline before and B after cutaneous 
irritation; C is the upper hepatic line. 

In my original paper, I advocated the rhigolene or 
ether spray as the best cutaneous irritant; since then, 
however, I have tested different modes of cutaneous irri- 
tation for clinical purposes, and I am now constrained 
to conclude that friction of the skin by means of a rub- 





Fig. 22.—Heart reflex in a boy aged fourteen years. Duration of reflex, 
fifty-five seconds. 
ber (the ordinary pencil eraser is suitable) is the best 
cutaneous irritant, for provoking this reflex. 

The nearer we approximate the precordial region and 
the more vigorous the cutaneous friction, other things 
being equal, the more pronounced is the heart reflex. 
The latter reflex may be slightly discharged, even 
though the cutaneous irritant be applied to remote parts 
of the body. In individuals with dilated hearts the 
reflex is very evident, and of much longer duration than 
in healthy hearts. 


240 THE BLUES :—NEURASTHENIA. 


In a previous communication * T espoused the theory 
that the real factor involved in balneo and mechano- 
therapeutics (Schott) was dependent, not on the baths 
and exercises as such, but owing to the cutaneous irri- 
tation evoked by these maneuvers. In accordance with 
this theory I have, since this contribution, employed 
vigorous cutaneous friction by means of hand-rubbers 
obtainable at any drug store, after immersion of the 
patient in a warm bath for fifteen minutes; the warm 
bath augmenting the sensitiveness of the skin. By this 
simple and expeditious method, in chronic heart dis- 
ease, I can adduce results emulating the conventional 
Schott method. Relief of dyspnea follows, there is re- 
duction in cardiac volume, besides a marked reduction 
in pulse rate, with increase in volume and force. 

The following conclusions may be formulated in ref- 
erence to my method of treatment and that of Schott. 

1. Lung dilation follows the exercise and bath treat- 
ment, the lung acting as an excretory channel for the 
overburdened heart. 

2. The cause of lung dilatation is dependent on 
cutaneous irritation, induced by the exercises and baths. 

3. <A decrease in the volume of the heart also ensues, 
and is likewise provoked by cutaneous irritation. 

In explanation of the heart and lung reflexes,+ we all 
recognize the influence of the skin in physiological and 
pathological conditions. According to v. Preuschen, 
stimulation of the respiratory center is greater through 
the cutaneous nerves than through the vagus branches of 
the respiratory organs. In animals, which have been 
made apneic, the application of cutaneous stimulation 
(cold water) induced stronger respiratory movements, 


* Medical News, Jan. 7, 1899. + Appendix, Notes 9 and 10. 


THE CAUSE AND CURE. 941 


and he concludes that mechanical cutaneous stimulation 
by flagellation, cold water, or the electric brush, is of 
the greatest value in stimulating the center of respira- 
tion. 

The center for the inhibitory nerves of the heart is 
stimulated reflexly by centripetal nerves. In support 
of this physiological axiom we need only recall the 
“ Klopf-Versuch ” of Goltz, which demonstrates that 
striking the abdomen in animals will inhibit the heart’s 
action. 

I regard the heart reflex test as pathognomonic and 
far exceeding all other methods yet recommended. in 
differentiating a dilatation of the heart from pericardial 
effusion. This is conceded to be one of the most difficult 
problems for the clinician. If, in a given case of in- 
creased cardiac dulness, which has been carefully out- 
lined, we vigorously rub the skin of the precordial re- 
gion by means of a rubber, and note after two minutes 
(the time necessary for the abolition of the lung reflex) 
a reduction in cardiac dulness, we are justified in con- 
cluding that we are dealing with cardiac dilatation and 
not with a pericardial effusion. Let me illustrate my 
meaning by reference to Figure (23). This is a 
rough reproduction of a reaction obtained in a young 
man with massive dilatation of both ventricles. <A, rep- 
resents the pereussional area of the heart before cu- 
taneous friction. The dark area represents the area of 
cardiac dulness after cutaneous irritation, and is caused 
not wholly by a reduction in cardiac volume, but also by 
the lung reflex of dilatation, which induces the lung to 
encroach on the area of cardiac dulness. After waiting 
two minutes, a time exceeding that necessary for the 
lung to recede, the percussional area B is obtained, 

16 


249 THE BLUES :—NEURASTHENIA. 


which actually represents the decrease in the cardiac 
area (heart reflex). If pericardial effusion were present 
there would be some evidence of the lung reflex, but not 
of the heart reflex. 

We have yet to learn the value of the heart reflex as 
an index to the condition of the myocardium.* 

Since the publication of the foregoing I have studiedt 










aa 


WET 
\ 


Fig. 23.—Illustration of heart reflex in Cardiac Dilatation. A, Percussional 
area of dilated heart. Dark area, percussional area after cutaneous friction. 
B, Percussional area, showing heart reflex persisting after abolition of the 
lung reflex. 
the heart reflex as an index to the condition of the myo- 
eardium, and find in brief that when the cardiac muscle 
is beyond restitution in myocarditis and valvular dis- 
eases the reflex cannot be elicited.. Heretofore this re- 
flex was only observed in the transverse cardiae diame- 
ter, but it may also be noted in the sagittal diameter. 

* The practical value of this reflex has been firmly established 
by the recent investigations of Merklen and Heitz in a paper be- 
fore the “ Société Medicale des Hospitaux ” on ‘‘ La Reflexe Car- 
diaque D’ Abrams” (La Presse Medicale, Aug. 1, 1908.) 

+ American Medicine, Jan. 3, 1903. 


THE CAUSE AND CURE. 943 


The recognition of the heart reflex will often aid us in 
excluding the murmurs of a relative insufficiency. Here 
vigorous rubbing of the precordium will temporarily 
dispel the latter murmurs. One may elicit the heart 
reflex by irritation of more remote regions. I refer in 
particular to the nose. Some years ago, I directed at- 
tention to the pulmonary neurosis of dilation, which 
could be evoked in almost every healthy person by irri- 
tation of the nasal mucosa, and that such irritation was 
inoperative if the mucosa were previously cocainized. 
- Later, I demonstrated that in persons suffering from 
asthma of presumable nasal origin, impacation of cotton 
in one or both nasal cavities would induce a typie asth- 
matic paroxysm. One may easily observe by aid of the 
X-rays that when ammonia is inhaled there is a decided 
recession of the cardiac ventricles (heart reflex), es- 
pecially the left, and that this heart reflex may be more 
pronounced than when discharged through the skin of 
the precordium. Ether and chloroform produce a simi- 
lar though less pronounced effect. With the nose closed, 
a similar though less pronounced effect of the vapors 
may be obtained, presumably by their action on the 
pharyngeal and laryngeal mucosa. In a few instances 
the vapors produced a veritable heart inhibition. [ 
could observe no diminution in the intensity of the heart 
tones during the inhalation of the vapors, yet the ac- 
companying sphygmogram (Figs. 24, 25) shows a de- 
cided difference in the output of blood into the general 
circulation before and after the inhalation of ammonia. 
These observations suggest the wise expedient of cocain- 
izing the nasal mucosa before using an anesthetic, and 
further suggest the cogent necessity of anesthetizing the 
pharyngeal and laryngeal mucosa. 


NOTE 9.—THE LUNG REFLEX OF DILATATION.* 


ANoTuUER Interesting phenomenon is what I have de- 
nominated the “ lung reflex.” It illustrates the impor- 
tant fact that the respiratory area may be influenced in- 
directly by stimuli acting on the vagi. Elsewhere I 
have shown the value of the lung reflex in diagnosis. 
Here I will only consider its relation to lung develop- 
ment. In a contribution by Mocueci, the suggestion 
was made that when ether was sprayed over the left half 
of the abdomen, marked reduction in volume of the 
spleen was observed in 12 cases. In repeating the experi- 


: Before ommmira, ine okationy 


So oa rele eS 
Bhs anc : 





Fig. 24.—Sphygmogram, showing condition of pulse before inhaling ame 
monia. 
ments, I likewise noticed a decided reduction in the area 
of splenic dulness in all individuals on whom this 
method was tried, irrespective of the fact whether en- 
largement of the spleen existed or not. Investigations 
convinced me that this diminution in the area of splenic 
dulness was not real, but only apparent. When the 
ether spray was directed over the region of the heart the 
percussional area of that organ was reduced at once; in 
fact, the superficial. area of cardiac dulness could be 
obliterated by the maneuver. Similarly, when the spray 
was directed over the hepatic region the superficial area 

* American Medicine, Feb, 15, 1902. 

244 


THE CAUSE AND CURE. 945 


of dulness of that organ could be reduced at once. 
When the spray was directed over the border of the 
lungs posteriorly, the lung borders could be made to de- 
scend from two to four inches, dependent on certain 
conditions. It was further ascertained that dislocation 
of the lung borders by forced inspiration never ap- 
proached the dilatation of the lungs produced by the 


—J \ / 





LSS Sy BENG SET SE iN 


at Pipe {ene f ~~ ap 
Fig. 25,—Showing effects of ammonia durlng inhalation, 


cutaneous application of the ether spray. Further ex- 
periments demonstrated in brief the fact, that the ap- 
plieation of any cutaneous irritant, whether the latter 
be mechanic, chemiec, or electric, would always induce 
acute dilatation of the lings. Even in emphysematous 
individuals the application of a cutaneous irritant still 
further augmented the existing lung dilatation. The 
question naturally arose, by what means could we es- 
tablish the fact that the application of any cutaneous: 
irritant would cause acute dilatation of the lungs, a con- 
dition which, it may be mentioned parenthetically, is 
only ofafew minutes duration. Such a hypothesis was 
made tenable by the aid of conventional physical signs, 
and the use of the fluoroscope. These aids show that 
when the skin is irritated by means of cold, by friction, 
or by a strong faradic current, lung dilatation will ensue. 
The degree of lung dilatation is dependent upon the 
character of the irritant, and the severity of its appli- 


246 THE BLUES :—NEURASTHENIA. 


cation. The response of the lung to dilatation is al- 
ways greatest in that part of the lung contiguous to the 
source of cutaneous irritation. Lung dilatation may 
be recognized by the following physical signs: 1. Di- 
minished respiratory excursions of the lung borders; 
2. Extension of the pulmonary percussion note and ob- 
literation of the cardiae and splenie¢ areas of dulness; 3. 
Hyperresonance of the lungs; 4. Obliteration of the 
apex beat. Auscultation is of no value as a physical 
sign, inasmuch as the artificial dilatation does not last 
longer than three minutes after the source of cutaneous 
irritation has been removed. Lung dilatation spreads 
from the source of cutaneous irritation involving pri- 
marily circumscribed parts. In lungs, showing dimin- 
ished resonance, the latter could always be increased by 
cutaneous irritation over the part pereussed. The X- 
rays show how the brightness of the lungs is increased 
by cutaneous irritation. By gradually applying the 
irritant to different parts of the skin of the thorax, one 
may note that eventually the entire lung may be made 
to yield a more intense luminosity. This increased 
luminosity, however, does not last longer than three 
minutes in the average person, after which time the 
lungs resume their normal appearance. 

In a number of measurements made during the study 
of the lung reflex after cutaneous irritation, I found 
the average dislocation of the lower border of the lung 
as follows: 


Righitisternal. Ines kis oeita site aes ase ales ee 3} cm, 
Right parastemal LnG se. %p.i una sein eo nices pokes 34 cm. 
Rightmammilary-lines, ..- 0s. 2st 4 cm. 


Right axillary line..... FS wisi sistene Weexs.c0t sy omen 


NOTE 10.—THE LUNG REFLEX OF CONTRACTION.* 


I wisn to direct attention to the Cherchevsky sign of 
early arteriosclerosis. This author contends that in 
normal conditions the diameter of the aorta varies at 
different times. It becomes dilated if the region over 
the arch is struck with the percussion hammer, while it 
shrinks in size if the blows are struck in the epigastrium. 
In arteriosclerosis it is impossible to produce these 
variations in diameter. The author has misinterpreted 
the phenomenon obtained by his maneuver. What he 
really elicits is a circumscribed ling contraction adja- 
cent to the part struck on the chest by the hammer and 
the blow on the epigastrium merely causes the collapsed 
lung area to dilate, thus supplanting dulness by reson- 
ance. Dull areas may be obtained in other chest re- 
gions, especially in proximity to the sternum and spine, 
if vigorous percussion is conducted. For this purpose, 
I use a large wooden mallet and a pleximeter of felt. 
The circumscribed dulness thus induced lasts but a few 
seconds, but may be made to disappear at once by strilk- 
ing the epigastrium. Observed with the rays in a sus- 
ceptible person, the phenomenon in question is a most 
interesting study. After the blow is struck, the adja- 
cent lung area becomes gradually dark, showing that the 
air has been expelled from the lungs, whereas in a few 
seconds the lung area becomes bright again. This re- 
flex cannot be obtained if the nasal mucosa has been 
previously cocainized, nor if the skin is irritated over 


* American Medicine, Jan. 3, 1908. 


247 


248 THE BLUES :—NEURASTHENIA. 


the lung area, for then the counter reflex of lung dilata- 
tion is elicited. The phenomenon just described I have 
called the lung reflex of contraction to distinguish it 
from the lung reflex of dilatation. 

The lung reflex of contraction has the same value in 
diagnosis and therapeutics as the counter reflex, but I 
will reserve its consideration for a future contribution. 
Suffice it to say at this time that we must hypothesize 
two distinet functions of the vagus, one which will 
enable it to dilate and fibers which can contract the 





Fig. 26.—Mallet and pleximeter for eliciting the lung reflex of contraction. 


bronchioles. This is the only hypothesis which per- 
mits us to explain the lung reflexes. Aufrecht has re- 
cently shown that the belief of only a circular layer con- 
stituting the musculature of the bronchi is wrong, and 
that by using the Biondi-Heidenhain stain a longi- 
tudinal muscular layer also exists. I contend, in view 
of this histologic fact, coupled with a knowledge of the 
lung reflexes and observations of asthmatics, that the 


THE CAUSE AND CURE. 249 


theory of asthma must not alone be based on a spasm of 
the circular fibers of the bronchi, but on an inability of 
the weaker longitudinal fibers to expel residual air im- 
prisoned by the circular fibers. In support of this 
theory I recall my observations with amyl nitrite. The 
primary effect of inhalation of this drug is to augment 
lung volume and then to diminish it so that its efficiency 
in arresting paroxysms of asthma is actually dependent 





Fig. 27.—The lung reflexes of dilatation and contraction ; A, normal areas of 
heart and upper liver border respectively ; LRD, region for eliciting lung re- 
flex of dilatation which, when struck, causes lung border to descend to B, and 
cover heart area almost to obliteration; LRC, regions for eliciting lung re- 
flex of contraction which causes lung borders to recede to C. 


on contraction of the longitudinal no longer antagon- 
ized by the circular fibers. This action has its analog 
in the bladder musculature when, in consequence of a 
spasm of the sphincter vesicae, the weak detrusor 
vesicae cannot expel the urine, and ischuria spastica 
results, 


250 THE BLUES :—NEURASTHENIA. 


Since the publication of the foregoing (American 
Medicine, Jan. 3, 1903, pages 11-15), I have been able 
to elicit the lung reflex of contraction after a manner 
which will bring both lungs simultaneously into a condi- 
tion of contraction. My observations with reference to 
the latter maneuver I believe to be of great therapeutic 
value, and they are to be embodied in a work which is 
now in course of preparation. 


NOTE 11.—SYMPATHETIC PAINS. 


Cririnicrans have for a long time recognized the fact 
that in disease and irritation of the internal organs, 
superficial pain and tenderness are often referred to 
remote parts of the body. Thus in cardiac and aortic 
disease, pain is experienced between the shoulders; a 
carious tooth causes pain in the ear, ete. Head, who 
has thoroughly investigated this subject, shows that. 
there is an intimate nervous connection between the 
viscera and definite skin areas, manifested by pain and 
tenderness appearing in sharply-localized regions on the 
surface when definite organs become disordered. He 
has also shown that in disease of the abdominal organs, 
pain and tenderness not only occur on the surface of 
the body, but the same pain and tenderness appear over 
certain areas of the scalp. He explains the topographic 
association of skin tenderness with visceral disease by 
assuming that the nerve-supplies of the parts so related 
find their origin within the same segment of the spinal 
eord: Thus, when -a painful stimulus is apphed to a 
part of low sensibility like an abdominal organ, which 
is in close central connection with a part of much greater 
sensibility, the pain produced is experienced in the part 
of higher sensibility rather than in the part of lower 
sensibility to which the stimulus was actually applied. 


251 


NOTE 12,—HEREDITY. 


Two factors are recognized by biologists as responsi- 
ble for the actions and character of the living organism, 
viz.: heredity and environment. It is often difficult to 
determine whether a specific vital phenomenon is a re- 
sult of inheritance or a reaction to environmental in- 
fluences. Resemblance to ancestors is an acknowledged 
product of inheritance. 

Galton has estimated that, of the total heritage of the 

‘child, each of two parents contributes one-fourth, each 
of the four grandparents one-sixteenth and the remain- 
ing one-fourth is handed down by more remote ancestors. 
The congenital resemblances may be anatomic, as ex- 
pressed by physical resemblances, (facial features, 
stature, color of hair and eyes) or by anatomic defects 
of the eyes, cleft palate, monstrosities, ete. They may 
be physiologic, as expressed by characteristic gestures, 
peculiarities in gait, tendency to obesity, to longevity, 
and to certain diseases, such as gout, asthma and epi- 
lepsy. They may be psychologic, as expressed by artis- 
tic and moral qualities, traits of character, temperament, 
mental diseases and proclivity to crime and _ suicide. 
Characters transmitted from grandparent to child and 
never appearing in the parent are referred to as latent 
characters. Latent characters are very often associated 
with sex. Character latent in the intermediate ancestor 
is evidenced by the appearance of the female characteris- 
tics in castrated males, and of male characteristics in fe- 
males with diseased ovaries. Latency isfurther expressed 
by atavism or reversion, terms which refer to the appear- 


202 


THE CAUSE AND CURE. 253 


ance in an individual of peculiarities known only in re- 
mote ancestors, but not in the parent of the individual. 
Darwin instances many examples of reversion, such as 
the frequent appearance of stripes upon the legs of 
the mule, the latter bemg a hybrid from the horse 
and the ass, both of which are comparatively unstriped, 
but are unquestionably descended from a striped zebra- 
like ancestor. The same writer attributes the degraded 
state of half-castes to reversion to a primitive savage 
condition, which, usually latent in both civilized and 
savage races, is made manifest in the offspring that re- 
sults from the union of both. Regeneration is likewise 
a phenomenon of heredity, and refers to the capacity of 
the organism to replace parts lost by accident or de- 
stroyed by disease. The regenerative power becomes 
progressively stronger as we descend in the scale of ani- 
mal life. Thus a newt may replace a lost leg, a crab 
a lost claw, the snail, an eye stalk or eye. A hydra’may 
be eut into pieces and each piece may re-grow into a 
complete hydra. If an earth-worm is divided, one-half 
may regenerate a new half which is in every respect 
complete. The Inheritance of disease is not always the 
transmission of an actual parental disease; on the con- 
trary, a diseased parent may produce offspring that are 
constitutionally weak, and the disease of the parent may 
later on attack the constitutionally weak body. With- 
out entering into a discussion of the theories of inheri- 
tance, modern biologists attribute much truth to the 
theories of preformation and epigenesis. The first is 
practically the Darwinian theory of pangenesis. It as- 
sumes that the cells or units of the body increase by 
cell-division or proliferation, retaining the same nature, 
and that they ultimately become converted into the 


954 _ THE BLUES .—NEURASHTENIA., 


various tissues and substances of the body. Aside from 
this means of increase, the cells throw off minute gran- 
ules which are dispersed throughout the whole system ; 
that these, when supplied with proper nutriment multi- 
ply by self-division and are ultimately developed into 
units hke those from which they were originally de- 
rived. These granules are collected from all parts of 
the system to contribute the sexual elements, and their 
development in the next generation forms a new being; 
but they are likewise capable of transmission in a dor- 
mant state to future generations, and may then be de- 
veloped. Their development depends on their union 
with other partially developed or nascent cells which 
precede them in the regular course of growth. The 
eranules are thrown off by every unit, not only during 
the adult state, but during each stage of development of 
every organism. The granules in their dormant state 
have a mutual affinity for each other, leading to their 
ageregation into buds or into the sexual elements. 
Therefore, it is not the reproductive organs or buds 
which generate new organisms, but the units of which 
each individual is composed. ‘Thus the theory of Dar- 
win explains the regeneration of lost parts by supposing 
that the granules of the part in question are dissemi- 
nated throughout the body and have only to unite with 
the nascent cells at the point of new growth. The theory 
also explains reversion by supposing that the granules 
lie dormant in one generation and develop in the next. 
It further explains how acquired variations may be co- 
genital, since an altered part throws off altered granules 
and by collection of these in the germ sells the alteration 
may be transmitted, thus explaining the transmission of 
acquired characters. ‘The theory of Epigenesis assumes 


—oe 


THE CAUSE AND CURE. 259 


that there is no preformation in the germ cells, but 
rather a lack of organization which during growth, un- 
der guidance of a mysterious power, gives place to dit- 
ferentiation and the appearance of definite parts. 
Much experimental work is now being done, chiefly on 
marine invertebrates, to determine how many of the 
characteristics of the offspring are due to the original 
qualities of the germ plasm and how much to the physi- 
cal, chemical and physiologic phenomena of the imme- 
diate environment of the developing embryo. Applying 
the foregoing facts to the heredity of nervous diseases, 
we have, first of all, the fact, that a nervous disease is 
rarely directly inherited. What is really transmitted 
is a general predisposition to nerve disease, the subjects 
having inherited unstable and irritable nervous systems, 
they possess, in other words, what is known as a neuro- 
pathic constitution. Individuals of genius are neuro- 
tics, as a rule, and may beget a progeny with neuropathic 
constitutions, but such a tendency would be less likely, 
if one of the parents were of a phlegmatic temperament. 
Shock or injuries to the mother during the early months 
of pregnancy may lead to nervousness in the offspring. 
There are so-ealled family diseases which may be trans- 
mitted by direct inheritance from parent to child, or 
may skip a generation. In the latter instance, we have 
a manifestation of atavism which rarely goes back more 
than two generations. 

Morbid traits, peculiar to a family, may reappear at 
the same age in the offspring, but if such traits show a 
tendency to disappear with each successive generation, 
they appear later in life in the descendants. If such 
traits become exaggerated, they appear at an earlier age 
-in the descendants. 


NOTE 13.—THE SINUSOIDAL CURRENT. 


Tue use of the Sinusoidal current in Electro Thera- 
peutics is of comparatively recent introduction, and 
even now its effects are not fully appreciated by physi- 
clans. 

The character of this current, when produced with 
proper apparatus, approximates a true alternating cur- 
rent curve. 

The use of this apparatus is to produce anaesthetic 
effects on the Sensory and Motor nerves; and by it, stim- 
ulation to muscular action can be obtained without the 
accompanying pain to the patient, which is attendant 
on the uses of other currents, if used in the same propor- 
tion. In consequence, a greater quantity of electricity 
ean be used than with the induction coil, so that more 
physiological action of the muscles is obtained than by 
other methods. J*urther, the more nearly the curve of 
the current approaches to the true sinusoidal, the less 
will be the effects resulting from polar action, thereby 
avoiding electrolysis and cataphoresis. 

The current is also found to be useful as a means of 
improving the nutrition of muscular tissue, and also 
for general muscular weakness. It also has the peculiar 
property of allaying pain, if the alternations are sufii- 
ciently rapid. 

There are four forms of this apparatus in use by phy- 
sicians. The first form is obtained by taking the cur- 
rent direct from alternating lighting mains, moderating 


256 


‘THE CAUSE AND CURE. 257 


the strength by controlling apparatus. The number of 
alternations per minute are limited to that of the cen- 
tral station. 

The second form is obtained by cutting the wires of 
any direct current motors, and obtaining one complete 
alternation for each revolution. The disadvantage of 
this apparatus is that the number of alternations is 
limited to the speed at which the motor can be operated, 
usually not exceeding 4000 to 6000 alternations per 
minute, and has the further disadvantage that the lines 
of magnetic force are cut by the revolving coils un- 
equally so as to form an irregular curve, and in many 
eases the apparatus is so designed that a change in the 
speed varies the strength of the field. 

The third form is obtained by using a direct current 
motor to run a magneto-electric machine, the alterna- 
tions of which are limited to the speed of the motor 
operating the magneto, unless belting is used, then the 
inequalities of the belt produce serious inequalities in 
the current. 

The fourth form has been invented by Dr. Kennelly, 
associated with Mr. Thomas A. Edison, and is designed 
to secure a true sine curve, a constant field, and increase 
the alternations sufficiently to obtain anaesthetic effects ; 
and constructed so that when belted to the motor it will 
obtain a frequency up to 150,000 alternations per 
minute. But this introduced belting causes irregulari- 
ties which to overcome the owner of the Kennelly patents 
has improved by designing and having built a motor 
that will develop an equally high frequency, using a 
direct connected couple; thus eliminating all belting 
troubles. 

The magnetic field of the Kennelly apparatus remains 


958 THE BLUES :—NEURASTHENIA. 


constant at all speeds, but may be varied in strength as 
desired. 


The strength of current in patients’ circuit is con- 
trolled by a high resistance rheostat. 


ph 
ngr Th 





Fig. 28.—Respiratory Massage. 





NOTE 14.—MASSAGE OF THE LIVER. 


Tradition has endowed the liver as a participating fac- 
tor in many morbid phenomena. Modern observation 
justifies tradition, insomuch as a disordered liver deter- 
mines temperament and manufactures ideas for weal or 
woe. Many philanthropic acts have been forever lost in 
the vagaries of an anomalous liver. The epigrammatist 
who said, “to be happy, one must have a bad heart and a 
good stomach,” aimed indirectly at the truth in ascribing 
our feeling of well-being to a perfect condition of the 
digestive apparatus. The observation of the older clini- 
cians still bears the imprint of truth, viz.: that the 
mental condition of patients is more cheerful in diseases 
above, than below the diaphragm. 

It is important for us to know that an hepatic anom- 
aly may exist without any clinical evidence of its exist- 
ence. Reference has already been made (page 151) to the 
beneficial action of the sinusoidal current in relieving 
hepatic congestion. I believe that much of this action is 
dependent on stimulation of the vaso-constrictor fibres in 
the portal vein. Mall, in 1892, demonstrated such fibres in 
the splanchnic nerve and that by their stimulation, twenty- 
seven per cent of the blood could be displaced from the 
splanchnic area and driven forward to the right heart. The 
conventional methods of liver massage are delusive, for 


the reason that they do not massage that organ. The 
iy? 259 


260 THE BLUES: NEURASTHENIA. 


nearest approach to liver massage is attained by vibratory 
massage of the liver region. I wish to direct attention to 
two methods of liver massage, executed by the patient, 
which are specially valuable: 1, respiratory massage, and, 
2, concussional massage. 

Resprratory Massacre.—We know that in correct ab- 
dominal breathing, the liver is rhythmically compressed 
between the diaphragm and anterior abdominal wall. 
We also know that if, for any reason, the abdominal walls 
are weakened, as occurs after pregnancy and tight- 
lacing, the liver is no longer adequately compressed in 
breathing, and thus there is a mechanical impediment to 
the active flow of bile, which favors the formation of 
gall-stones. We are able to duplicate and accentuate 
physiologic compression of the liver by substituting the 
fingers of the patient for the anterior abdominal wall. 
Reference is made to figure 28. The crosses are placed 
respectively in the median line, in the region between 
the nipple and the sternum, and in the nipple line. The 
crosses indicate the different regions of the liver to be 
subjected to respiratory massage. The patient bends 
slightly forward and inserts the tips of his fingers deeply 
into the upper abdominal region, and while maintaining 
firm pressure takes a forced inspiration. I direct my 
patients to commence with ten deep inspirations at each 
cross and with successive morning and evening exercises 
to increase the number to twenty. The exercises may 
likewise be taken in the recumbent posture with the 
thighs flexed on the abdomen. 

Concuss1ionaL Massace.—lIt is difficult to palpate the 
liver, and for this reason, its anomalous sensitiveness 
often escapes detection. If, however, the one hand (Fig. 
29) is placed in contact with the liver region (shaded 








Fig. 29.—Concussional Massage. 








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ve rey t : Z t . WW ic iva Oy eae ¥ 
d ub de of , A: oi A 
ks eS ce Ome gt ee et. 
f mY ; 7 : 
P } | Jt ia iy a as . Disa hls 
; / ‘ek. ae ae 
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F , 1 ots Lae 4 ia f 
5 ivry y ath) tk ed PO ‘oe PLT 





} en, Se ELE ety ae ay, | s ; 
EE Le ee utr ey es ey ea 


THE CAUSE AND CURE. 263 


area), and with the fist of the other hand, the fingers of 
the hand in proximity with the chest is struck a series of 
blows, the latter are transmitted to the liver, and its 
sensitiveness is revealed. From numerous observations 
made, I am justified in concluding that the irritability 
of an individual is in direct proportion to the degree of 
sensitiveness of his liver elicited after this manner. As 
the sensitiveness of the liver is reduced after concussional 
exercise, there is a corresponding reduction of the indi- 
vidual’s irritability. Of course I refer in these observa- 
tions to the splanchnic neurasthenic. Concussional mas- 
sage is executed twice daily over various points in the liver 
region (shaded area) after respiratory massage, striking 
the fingers of the one hand in the total exercise from 20 
to 100 blows of varying degrees of force. The equestrian 
achieves his hygienic results in consequence of vibration 
of the abdominal organs, which corrects digestive troubles, 
constipation, and hepatic affections. Liver massage after 
the manner recited, taken but once a day, is equivalent to 
a horseback ride of many miles, 


264 THE BLUES : NEURASTHENIA, 


NOTE 15.—HUMAN METABOLISM. 


There is much concerning nutrition that we know, and 
a great deal more that we donot know. What is known 
as a catalyzer, is a substance that by its presence alone 
initiates chemic reactions, which otherwise would not 
oceur, or accelerates or inhibits such reactions. A conspic- 
uous paradigm of catalysis is noted, when the mere pres- 
ence of platinum hastens the burning of hydrogen gas in 
oxygen at relatively low temperatures. Animal tissues 
can disintegrate the albumen molecule, and the effect cor- 
responds to the action of the pancreatic and gastric 
juices. This tissue digestion was referred to as auto- 
digestion, but the term autolysis has been substituted. 
The term metabolism is used to indicate the phenomena 
attendant on cell nutrition, etc; i.e, the selection and 
absorption of food, its digestion and the elimination of 
waste-products by the intracellular ferments called 
enzymes. Wells* says: “All metabolism may be con- 
sidered as a continuous attempt at establishment of 
equilibrium ” and the “living body, whether unicellular 
or multicellular, is a vast, unceasing series of chemic re- 
actions.” What concerns the pancreatic secretion may 
eventually hold good for the other digestive secretions. 
It has been shown that the pancreatic secretion has not 
only a direct influence as a digestive agent, but that when 
absorbed, as occurs in pancreatic disease, it interferes with 
the intracellular digestion of fat and sugar. Thus in 


* Journal of the A. M. A., Jan. 25, 1902. Lewis-American 
Medicine, Aug. 12, 1905. 


THE CAUSE AND CURE. 265 


diabetes, which is probably the resnlt of structural 
changes in the pancreas, there is an increased amount of 
fat in the blood.* Lewis ¢ has .recently studied this 
subject in a practical direction, and I believe that his 
observations will prove of material benefit in the treat- 
ment of disease, the underlying factor in many instances 
being merely nutritive disturbances which have invited 
the accidental presence of germs. Lewis has investigated 
tuberculosis, the susceptibility to which, he suggests, is 
caused by some break or perversion somewhere in the 
sequence of enzyme action. In diabetes, incipient tuber- 
culosis, and chronic digestive disturbances, he continues, 
there is a marked increase in the presence of sugars 
and fats in the blood and urine. He believes that the 
ferment action of the cells is profoundly influenced by 
oxygen, hence the prestige of the open air treatment in 
tuberculosis. He has derived much benefit in his tuber- 
culosis cases from hypodermic injections of active 
sterile preparations of fresh pancreatic gland. He rea- 
sons, that the immediate introduction of pancreative 
extract into the blood energizes or vitalizes the dormant 
action of the intracellular ferments. 


* Zeitschrift f. Klin. Med. xliii., Heft, 1 and 2. American 
Journal of Physiology, vol. ix, p. 380. 
+ American Medicine, Aug. 12, 1905. 


266 THE BLUES: NEURASTHENIA, 


NOTE 16.—CHEMICAL DEMONSTRATION OF THE ACTION 
OF THE SINUSOIDAL CURRENT. 


That the abdominal application (one large electrode 
placed to the right and another to the left of the navel) 
of this current increases the absorption of the products 
of intestinal putrefaction, is evidenced by numerous 
investigations in my laboratory. It was found that not 
only indican, but likewise the ethereal sulphates were 
increased in the urine after the abdominal application 
of the current.* This fact further accentuates the 
therapeutic value of the sinusoidal current. My results 
were obtained with a current of not more than 8,000 
alternations per minute. An increased frequency of 
alternations is unnecessary and less effective. 


*This subject is further elaborated in my most recent pub- 
lication, ‘‘ Man and His Poisons,” E. B. Treat & Co., New York. 


THE CAUSE AND CURE, 267 


NOTE 17.—TESTING INTRA-ABDOMINAL TENSION. 


Minor grades of reduced intra-abdominal tension may 
exist without being detected. One method which I have 
elaborated and which [ regard as trustworthy, is the follow- 
- ing: having auscultated the heart tones, palpated the pulse, 
defined by percussion the borders of the heart and esti- 
mated the blood pressure in the erect posture, I have an 
assistant stand behind the patient. The assistant with 
his hands lifts the abdomen of the patient quite firmly 
and forcibly upwards and steadily maintains this pres- 
sure while the physician again executes the foregoing 
methods of examination. One finds even in minor grades 
of reduced abdominal tension the following: the heart 
tones become stronger than before the abdomen was sup- 
ported, the pulse becomes endowed with more character 
as is evidenced by palpation, but particularly by the 
sphygmogram, the percussional areas of the heart and 
liver become higher and more pronounced, and the blood 
pressure is augmented from 5 to 80 mm. The aitered 
clinical symptoms are caused by heart prolapse (cardio- 
ptosis), which observation has taught me, is an almost con- 
stant symptom, in diminished intra-abdominal tension. 
I find that a leather belt sufficiently broad and which 
can be adjusted by the patient with varying degrees of 
pressure is one of the best, simplest and cheapest abdom- 
inal supporters. It matters little where the location of* 
the abdominal pressure resides as long as the latter is 
augmented. With such a support as described, the 


268 THE BLUES: NEURASTHENIA. 


abdomen below the belt bulges, but this seems in no wise 
to influence the relief obtained by the patient. The 
percussional method of determining abdominal tension is 
as follows: I first percuss the abdomen, then I ask the 
patient to bear down as if he were attempting to void his 
intestinal contents, then I percuss again. In proportion 
to the degree of tension, the percussion note, during the 
time the patient is bearing down becomes translated from 
a tympanitic before, to a tympanitically dull, dull or even 
flat sound. The flatter the sound, the greater the degree 
of tension. In diminished tension, no change in the per- 
cussion note is evident. In constipated individuals, the 
latter fact is likewise evident, and I believe that consti- 
pation may often be determined after this manner with- 
out questioning the patient. The percussional changes 
are most evident during the time the patient is standing, 
and percussion of the lower half of the abdomen can be 
accepted as the only criterion. 


THE CAUSE AND CURE. 269 


NOTE 18.—PERCUSSION OF THE STOMACH. 


Numerous methods have been suggested for determin- 
ing the lower border of the stomach. The employment 
of what I have called the stomach reflex,* suffices to out- 
line the lower stomach border. Ordinary percussion 
will not differentiate gastric from intestinal tympany. 
' Tf, however, we concuss the Traube area after the man- 
ner suggested in concussion massage of the liver (Fig. 
29), a series of vigorous blows and then proceed to per- 
cuss the stomach region, one finds that the latter area 
which formerly yielded a tympanitic sound now evokes 
a tympanitically dull or even flat sound (stomach reflex 
of contraction.) The Traube area is that percussional 
half-moon shaped space which normally yields on per- 
cussion, a tympanitic sound, owing to the presence of 
the cardiac end of the stomach. The Traube area is 
bounded above and laterally by the contiguous borders of 
the liver, lung and spleen. By striking the blows in the 
Traube area, we render the gastric walls tense and when 
air or gas in the stomach is under considerable tension, 
pitch becomes higher, and the volume and intensity so 
decrease, that percussion will elicit a dull sound or dull 
tympanicity. 

The stomach reflex of contraction is most conspicuous 
when the patient is examined before the Roentgen rays. 
According to this method the stomach is moderately dis- 
tended by air after the conventional manner, and then 
concussion is executed in the Traube area. One at once 
observes after administration of the vigorous percussion 
blows that the fundus of the stomach will recede fully 
an inch or more. 


* Medical Record, Sept. 3, 1904. . Medicine, Jan. 1904, 


979 THE BLUES: NEURASTHENIA. 


der of the stomach (by percussion), after concussing the 
Traube area. The greater the distance between A. and 
B. the greater the motor power of the stomach. In the 
norm, the degree of retraction in the median line is from 
2to5cm. I have found that when one large electrode is 
fixed in the Traube area and the other electrode at an in- 
different point in the back, that with the sinusoidal 
current, the stomach can be brought into a state of con- 
traction. The latter fact suggests the importance of the 
stomach reflex of contraction in the treatment of gastric 
affections. . 


CEREBRAL ANAEMIA. 
VERTICO. 
FAINTNESS, 

and 
SYNCOPE. 












SUP. 
VENA 
CAVA 


SUP. 
VENA 
CAVA © | concesriow 


SCANTY URINE 


NEPATIC, 
VEINS. | 


INP. 
VENA— 
CAVA 


STOMACH 


CONGESTION. _ | GASTRIC CATARAH. 


ENLARGEMENT. 


E | : x + 6@\ Na \ 
IAG Vays {Og \ 


COLO POWER [CILAGSAR US: 
EXTREMITIES. INTESTINAL CATARRH. 
OBSTINATE DIARRHOEA. 
OR 


CONSTIPATION. 


FIG. 31.—Demonstrates the circulation of the blood and the effects of splanchnic 
congestion on the abdominal organs. (Modified from Butler. ) 





THE CAUSE AND CURE. 275 


NOTE 19.—THE VASOMOTOR TEST IN SPLANCHNIC NEU- 
RASTHENIA. 


Reference has already been made to the vasomotor 
factor (page 116) and the demonstration of splanchnic 
congestion by aid of the cardio-splanchnic phenomenon 
(Note 2, appendix). Here we will accord brief attention 
to what Crampton * calls, the “test of condition ” which 
is equally available in recognizing splanchnic neurasthe- 
nia. The splanchnic circulation (Fig. 81) properly signi- 
fies the arterial branches of the celiac axis, their branches 
and the radicles of the portal vein. This system is partly 
arterial and partly venous. The erect posture of man 
places him at a disadvantage in several directions, notably, 
however, by increasing the height of the blood-column 
with a corresponding increase of gravity on the circula- 
tion, thus causing the blood to gravitate into the splanch- 
nic vessels. Among the resources of Nature to combat 
this tendency the vigor of the abdominal muscles is para- 
mount. The vasomotor factor is likewise predominant. 
In standing, the splanchnic vessels are constricted by the 
vasomotor action of the splanchnic nerves. If this con- 
traction is effective against the augmented pressure 
brought to bear through the gravity, the blood-pressure 
in the upper body rises, and, if ineffective, it fails to rise 
or falls. The splanchnic vasomotor mechanism is the 
latest in the body to develop and it appears only after 
man has taken to the erect position. The mechanism in 


* The Medical News, Sept. 16, 1905. 


276 THE BLUES :—NEURASTHENIA. 


question is easily fatigued and according to my observa- 
tions, its exhaustion is one of the earliest expressions of 
splanchnic neurasthenia. When the blood-pressure falls, 
the heart-rate is accelerated. If the rate of the heart is 
increased with an augmentation of blood-pressure, it in- 
dicates a relative insufficiency of the splanchnic mechan- 
ism, for the ideal condition, is a rise of pressure with no 
acceleration of the heart on standing. In employing this 
test, the patient is directed to lie down flat upon a couch 
with no head-rest. The armlet of the blood-pressure in- 
strument is placed around the upper arm so that it bears 
the same relation to the heart lying as it will when the 
patient is standing, thus eliminating any hydrostatic 
error. After the average pulse-rate is taken, the systolic 
blood-pressure is determined. The pulse-rate and-pres- 
sure are again estimated in the erect posture. The patient 
must be allowed sufficient rest in both instances before 
estimates are made, insomuch as the muscular effort alone 
will modify the pulse-rate and-pressure. In the follow- 
ing case the test shows an adequate automatism of the 
splanchnic vasomotor mechanism and demonstrates a 
good condition : 


Pulse-Rate. Systolic Pressure. 
Lying.— 58 120mm. 
Standing.— 58 132mm. 
Difference.— 0 +12 


The following case shows a poor record and demon- 
strates an insufficient splanchnic vasomotor mechanism : 


Rate. Pressure. 
Lying. — 68 100 
Standing.— 104 94 


os 


Difference.— +36 —6 mm. 


THE CAUSE AND CURE. vine 


More accurate conclusions may be formulated when the 
condition is already known and the test in question may 
be accepted as a means of indicating the progress made 
in chronic cases and the value of the remedies employed. 





1 


: . M ony 


= 
> 


BIBLIOGRAPHY. 


Shattuck Lecture—‘‘ Not the disease only, but also the man.” 


. Journal American Med. Assoc., March 7, 1903. 
. Medical Record, Nov. 22, 1902. 

. Journal of Morphology, Boston, 1892. 

. Clinical Lectures on Neurasthenia, 1902. 


Sexual Neurasthenia, Beard and Rockwell, 1895. New Ed. 
1902. 


. Weiner Klin. Wochenschrift, Nos. 2, 4, 5, and 7, 1898. 

. Corresp. f. Schweizer Aerzte, No. 6, 1897. 

. Medical Record, Feb. 5, 1898. 

. Medical News, June 25, 1898. 

. The Lancet, Jan. 21, 1903. 

. Auto-intoxication in disease, 1894. 

. Ueber habituelle Stuhlverstopfung deren Ursache u. Behand-. 


lung. Berlin, 1891. 


. Blutdruck und Darmatonie, 1894. 

. Clinical Lectures on Neurasthenia, 1902. | 
. Croonian Lectures: British Medical Journal, vol. 1895, p. 6. 
. Archives Gén. de Méd., Dec. 1892. 

. Wiener Klin. Wochenschrift, June 16, 1898. 

. American Medicine, Feb. 15, 1902. 

. Text-book of Nervous Diseases, 1901. 

. Clinical Lectures on Neurasthenia, 1902. 

. Deutsch. Med. Wochenshrift, 1896, pp. 53, 73, 87. 

. Revue des Maladies de la Nutrition, 1896, pp. 723, 724. 
. Journal of Physiology, vol. xxi, p. 323, 

. Respiratory Exercises, 1898, p. 12. 

. Journal of Physiology, vol. vii, p. 202. 

. Lancet, 1894, vol. i, p. 587. 

. Respiratory Exercises, p. 86. 

. Phil. Med. Journal, Dec. 7, 1901. 

. Volkmann’s Sammlungen, Nos. 115, 116, 1895. 

. Archiv. f. Verdauungsk, Bd. ii, 1896, pp. 285-295, 

. Text-book of Physiology, 1893, p. 71. 

. Therapeutic Gazette, July 15, 1901. 

. Halliburton’s Kirke’s Physiology, p. 587. 

. Verhandl. d. Congr. f. innere Med. 1897, pp. 521-523. 
. Journal of Physiology, vol. xxi, p. 323. 


INDEX. 


PAGE 

Abdomen, sensitiveness Of........ccccscccccecs SAA tianor err 127 
Bet Fe Le hanes o's chk os os Kona PRR i. 150 
REE UCL eee Neel ich gS wiecaicceie! waivie.of Sala Ge. sad efecintie 117 
SRE OB ts se hss aid eb a oie w nc onhe Wel ne e ondahd yas 138, 141 
muscles, exercise of.......... Marctivticin aot ack al eter vies wins 4 143 

cree ere Leelee Saat tens ET rn comin, od UR ee » 3g athe 46 

re PE UG Tue inet ate ane tie pie ia aie wa os A Ran nie 152 
ODALETIE ART aR oat ays Fe ee i ge Ur rea 116 
MR YA ee eeepc asc hcg a blo om abe $4 sla dotate ake 125 
Atfeccion, diminished... ...0...i0000.e RttAS Te aceatae te ART os 59 
Ree Ree cee ee OO eis 66 vis-'s Sc.9 ba peek.’ aia ee 8 aes 29 
erremate PETA TI QUALY yi eterc cere wes +,«, a tere sue es van elec vers « 63, 189, 196 
Angiopathic neurasthenia. PA errr sip cals ow aiae onal et Saptema 13 
Ieee ee evince chy erred cescdnc ts secuaetea 63, 132 
Ree POICLOUOG aia asi was ta 4 eele 8c; 4 03.8% ss bes cus.e eee 183 
EPEC UIC ois Lobes alos cosieses 0 Cavs oie ne a sia 8 le gl oe 179 
See IS MIS-OITILONL Vin clon tig Wo cles say blac gies 6s trcc6s so dasuiesiae.« 257 
Se PEA UL Sree a cre ia wis < oic tc cieidieait nie core 4 0.0¢ st a os Suse os fie 216 
ee rs coat feats h ie OOM 3 0G sic ew tdi dae Geen van be 252 
SEE CPRCUZOMIOS eee ties os oa ee kale ore woe ear ee te. (e oaie tne 191 
Seeremer mere OOLCUSSION weiss vcloe as soy doe ene ur was ees 222 
Dee MMP REMMI eet (TOV Oe ae cices son o:d Sere, 6k Sls FSee Rely men oe SE Re 45 
Auto-intoxication, factors which determine............. oe ou OG 
Tee NEULASLNODIA. « © «se sia s'oa'su's 0s inn 04 6.0, 010 4 /eainteee aa 44 
EC TEE ag ¢ LaF. eat wnin'a. CHR ie 810 hela che ied ue elelneitiace 56 
BRINE UT el ae os sats oy cries nis vse 6 cea! Cake cin tse ne Sinn lala 119, 215 
TE a Toe ee cy cele v's cclsc ea bese deny ves ae tees rile | 
MPEP COMI hl oe op cvs bes vols dd'ee 3 es = witha dis & siacaleh meaner La by 
OE A Se Ne viaties bac ete sets co eecucakans s Peek ean wim ats 58 
Bawels, LAS IDs... ssccecee PAN es CEO SOCAN Pe 


281 


989 INDEX. 


; PAGE 
Bread and fruit diet.......... rer ice ce b uenen) Seer 187 
Breathing -OXercises.....s.sscoessesoesns ceden ss neal ee 233 
Cardio-splanchnic phenomenon, .........ccsesccsecssncsss 116, 200 
Casque neurasthonique, .... hows caves oncu soe nea nee 55 
Change of life seis os ea dclb a oh peas oh waa «ne cee via wiarragate 32 
Cholmeiai.. fr Sens acs sco a's a's mre le’ rele ¥ied-ce” lc alates 00 at en 175 
Ghristian SClenCOr.e 2c. sus sess ee Ged ches aeuun ahem do stern ua 
Colon, action‘on heart. s..6.: 2<%+« ses .0 ones sacs elle eee 218 
Cocoarr. st reeses aes cP ub vase oh ob's b o5.c 90a 940 0.9 ke Ree . 380 
Coffee. ive ah Sees haa Cai ob eu bvee Waban oy sea Uae ee anne 30 
Conceptions, imperative. ....so.ssssc+s cue sates evn ener eeeee 59 
Congestive neurasthenia.....: 10. . 55.0005 a0 leave © sects hens 41 
Conjugal hy gine; sc s.cccsciv ews oes res cine ob ao“li sabe Ueeteiets 101 
Constipation, treatment of] 7.2. osc. ce<- ess svc ce ne oa 100 
Constitution, neuropathic......... Pre err Pen 255 
Costa fluctuans ‘decimai:2.\. 2... Gsnk soa sw 0% sive tenet decreas 125 
Cures Teshis ss 455i. Pyke Cae en ei ae veces cee ele Cee 83 
Current; SInUsOldal ge .wnee sce Sele g masrale «a hae Cue 151, 256 
Curve of health (s.ns.ee-s Sins a oS toni hp oieels Viale ROIs PPP 
DPT OATS. 65 c1cs cic iate! sxghola’ 5 slerotevete lute i ail stotee! aint winte chara setae eels e's eee 95 
Dyspepsia, MOT VOUS... (cra ciermteiecasteletsie sic e'vrsia's © er eiv ule aistiemiets RE at 
Dyspeptics, rules for........ Seek oetpuneius's oe ou ealeaacs se RN 
Ear signs ...... SR ey ct bs en 0. 1s 6.0.0) aie as ete ete aannnn 
Edinger; 1a wi0L. secs oes coerce s on aw be 6s 0 ae css 0 sles oslsn tee 36 
Electricity to abdomen.......scesesece ove dvs cece os ue een 
Himissiona, Semiinale tes: oe setae Soaks Gere is tees eeeeee 
Hnteritis;-mucous.c seve eee ees oe oe veceeh AP sc iy, i 
ENteroptosis <5... cee sees s secevesesceses sume ces eave 
Estimation of the solids............ cave ce¢ eves slcr@ snemnnnE 175 
Kthereal sulphates...........- Gs ste cp wir eros valve obs scat ateRteeiaan 171 
Examination of liver....... Galwid's bee's 4 -a's'4 se a este oietrnenee che eeneeU 
Exercises; abdominal, 552.042.6530 cecnsseasceeaa tube 143 

breathing......... Ca ean see A Or ooh Pa F:5 233 
Tespiratory 235 esa terete. ddeserdceducss sesh ents . 148 
Hy SICNS Shae. wcccw eens sews cvcecsetevecececcsnn cian 


SELON. 's sss Whe eins oS boas ' le dies eles 'ele's'o's's'p c/a 1a eo a atari 57 


INDEX. 983 


PAGE 
TUAMMIY CISOASON sac ccseiedescecs seve Gore racipens Nepisheed tenes «200 
Farinaceous aliments,.... peerdw'oisiaseura salute 6 ahs caveveseowwns el Lor 
BaP EEE Ct TISTIADTUIESS © Fania ora'4 «'a:s’s se sein i'n sine. o'n 8 | 8 Ra wale Pea ets 
Foerster’s shifting type......... Se ae Oe Pie dics ate the ak oF EOS 
PROD gad ess 6G wia.s'se Birla ter eretoralé Winters Sa AM Aree Ria tas te ee ries 1G5: 
ECR OS gral Sala a 'g vce o's ofr aoiaek ame Soa om COPPER CERES >: 55 
Pe CEPECLIEV GUO dere 5 ce vies pecue wun o's ea eee © Sia otetioche sre tet 26 
REGAL pea DILAGIOI, Of. ovccec.0ce0s ese ve cehise divs ws ee eoeiuste 95 * 
BMT ca eel inlets vives © ho 4K a a orale iste ty-un cabeiiciaia ate wae 237 
eT tS ates an cis PA Bala bee o'sieca.e fee ele.e the ee yaar 61 
WHER ITIGSH 9. a ois «0: ete iets See oe ise Suit aninde sage a a eare eae word 131 
Pre ORIGULLOCUGV soe", ge pics a6 sists smc a acvc sca caw tr can s 174 
RR Ae rear ie cg iy eee ek spies’ e ds aiviv oe o'9 oho mvenke!s 18, 21, 252 
Human Metabolism, 264 ; Hydrotherapy..... MEP EERE 93 
Hyeiene; conjugal, ,...+.<9<. RaME aie daca t apes ar rey ee voayeelue 
1 OYRTCEIAT D2 of pe US lp ater GAAS A agra nee a ee 20, 25 
Ru CIE Mer cere een as weisa asian) oo.6(d seus clzw = ans 5 e'ene.s « 94, 103 
PMIRCHUTIA GS co nung a afin okt ey vice ae) b, 05 s10 0 eso ee ees ¢ 4 174 
Hey MOCHONGLIEG, SEXUAL joss 2c cs sec diacecns ON PR eae 69 
BA ee OLULELASIG «1g ie av otek v's v's s «o's <u» 0% 0's Shahar cesar ee eee 47, 5 
ee te eit dia ok mnne caine Gl UL eat 6 Sed oso. Vie vida weet 75 
BOTA DL VECOUCODULOUS 5.2 sicciie «sce. csirc.s ees © ¥,0°0 ade were (Oo 
Re ee TN comrreeee aren wah ou aC <igiee ys iis cag cs ese ech sae ea cee 68, 70 
MMAR EIGN Savers ticalere nia: fia uieiscacon nya esd «as sicie sso ean eel 59 
Se ieee Os fee aise exe Chea eee eon he case cae eee ean 172 
Indican, tests for..... We dad ars a eee ak rier eer cere yee 173 
NEO PTIGEVOUSH nse of on's chek 6 acpe Sas neem Slee PEN ke Seioe 64 
eee EM eet ae cle fal a nie k 5 3s Wis oe 4:5 Wes ve.eicie «Gace otis ake al 
eM MRSIIGULASENOUIG «is asso ces cesses so 's.0.9 see sip eure si ae ck 77 
Insomnia..... gS ES PAGES EE ESE CCE ERO ee Pye Re STE So 
PR ea Tea Ate cana a sic caw ess Gases we es cad Cade mete dies 92 
symptoms of......... Ge Cate ma ee tenis vimatd genes ane lee 91 
Be eeETE PIN ROE te Sie elela Wr sae ek aie o'> Via's & sls.aleiew-c «ta aaislaniasters 91 
Intestinal antiseptics............ FEAL Pre Se oer RP NIA EE 185 
Intestinal auto-intoxication ............ aan Pe ee wren Ne 161 
Intestinal auto-intoxication, the diagnosis of..... Are tic 169 


“ 66 6 SVEIPLOMS Clos cso 6 ee anna es 168 


284 INDEX. 


PAGE 
Intestinal auto-intoxication, treatment oOf.........seeeceese6 178 
Intra-abdominal Pressure <es cuss cecdswe, sehen ein <a Galalele Sele gmee ome 
Irritation; spinal: xs ¢ cade sce Sieie elect oyaye'e we CEE Jtheeeee 72 
i<ennoelly apparauus cs eco. sone en ee Ss viele siw'ee vis, 60) clacee ee 257 
Kilgpt-V crsticiies + tee aie oe ne cists este olsieie <\€ 6 ates aletenetd on a oh PEE 
Lithemias 02.2... 2 ects thes te etsaeseas bese ped adeeaven bed Oe We 
Liver border, 224, Liver Massage.......... bieeed. Fe apa 259 
enlarpement: Of. + 17.5%... 2% sess bane es whi eu Bon o's vid Siete SO 128 
examination ols 692 is ie0254 dt et ada st 2 ceonumdas eee 22 
palpation of: 629 2ss559 Sy. teens S20 004 Dies aoe ceo 220 
POTCUSSION. OF 1, 58.10%. '.20's'cle 'sin'ats’ole Pol he'e lal sdoterets a Vanete ones an 221 
TOHOR LoS. pds Ie ae Pad Co a aaa ee ee Se 129, 230 
Lung, antedating tuberculosis. 20.5 6211 iiss0t.s.00+ sa un eeee 233 
development insufficient,..............000- atihiaace ve oeeerem 131 
reflex of contraction: s: 25%. 6is9 #204 6000 ecko dese 247 
reflex of ‘dilatation 2.2.4.4... 5 42teat eet sence ae Loree 244 
Massage 188; Massage of Liver. . 2.5... .0<es +. ses aie sane 259 
Masturbation; Avs cscek ce coaceys one meee es ae ene Bae Stier 71 
Meltincholia 39 ysis oy 5 sed pele soe ete eos eae te 76 
Dlenopause 32s Meta polism: Vesa... cs eee eee. «ace aye ae 264 
MAL 6 sharin atten Stee ie ee eR ES ee eee ea nie'e «aa 5 dg segs ae 180 
Morbid fears’, snc % sc slew aly Cmte Wie eeteiaies ves a. tanaris St eet os 58 
AIL PUISES We ii jceie wales cs tate bia dick wo eis’ o.e, «oe ans, ofan soe 59 
Mucous enteritis rcs). Ves ane chee ue nue ee ce ee ee 67 
Muscular fatigue: ..2 occu ccass.c eo vs os tienminie ois eae ee 53 
INET V6; TOOUS eke SA Slate he te «| sNeiialis) whe brakes 0) stands te ee 30 
Nervous’dyspepsias 223% 2:5 120255 oats 63 0 ee. alapere blesom ers re tenn 96 
Néurasthenia, ‘abdominals: 2.53.2. velewis ve cdenses st see 46 
AUCOLOMOMIC Sf ite wishes heiais esate helio! “Bhi ec eee 44 
DiGod Anis. eek g SHAE NSS ES ons beds mae 5s ep ee een 63 
Drain’ SIPNS iN Fs 5. 4 REE et ot cer ee ee os ae 58 
brain chanpyesriny 2540.50 stots oe atelier ry ee 33 
CONPESEIVES | 05 FE be als ela d atahaoie ol octets wie ole ac ane 41 
arid dyspepsian. i. srs sess 0/0 % dilate mn s/e: slr orn otcha stale te 48 
HY SIONS AN 5.554424 tos eso Coe lined tin vies een 58 
SVE SloMs Us i. . Laie ais oem wists estes lots Ollvae Gotersteeese opt en 56 


INDEX. gg 


PAGE 

Neurasthenia, heart signs of............ i taeeele ovine siederen . 61 
Ma WMRRLM TP RLIUS OL Go were era-old nace hans lado tar des ie oncdeSewes 65 
RANE TUS AS ith cr fayth ane¥eishatoiele so’ igs, Sie dicka, viemiaeiat few eels bee 23, 39 
BeSIOLORIC TACtOTS Iino. o.0.c.00p.0'0)0 cb eb Btansje oh eee *. 82, 
PEMD eine s Fog y se cass 64 ae 4 ano fide eps belo bats « Bde! Oe! 
PATI ONG hee crane gain id's ok 2d ARS AS so Area ben 62 
PMeE MR cue Cache enn oor ep fie ip ee ber esd eu rae’ 40, 67, 101 
Seis LAVIN LOINS Ol nec eww ame o'e'sp weiss 9 3 dA aal eee sy sty aah 53 

Ree PRMICMTARS Te VETS GOs erst igh nl! e/673:6/5; 6/40 ¢ & © 08 ore'e eed wae 111 

See MCARMECIOTIS OA nadine nieve ssg eae bode Teds sted sega 64 
BERET ANE SEEMED Toca (oie 3063 picix'S ork «4's Ns ns 4 oe a is, 0 sted sole wb lal ble 32 

BEG EMICRUAOL sii205 8a cnn mmabicn pple Spey oer Ce oe 81 

MUU SPEIM UL Se swibie <aiée wie he @ 5 $0 RAT 2 Peri Son 42 
Rs E OM eIStUT COS: OL os be aie’n Ge hince's > i'w ie'a'o sole @uSa =e 80 63 
Reepenee Ga TOLLE TIC. fos, os lalstne afbacte 10 .5 Alm alsa" 4e nace Ck a's 35 
Mae eee eae de ei fe orate a Risteulddisie vig s's's srasia vitesse d ciate vos 77 

er ENR EE GUN Got ie CBr ats a ais oltg wool oa eae ahi s hie Riols' 6 Pare ss 35 
Pet ea a ICONSUILULION. voec tees Sak sca 8s ons s tar viie se ee nee 255 
PUSEEIGLGPMOTOOILY . eis n cm casper ee sines sss Pee ese Snes sf 17 
Rm Ce Fes oiede Ci se eRe eal a Ho vasa Was s\ardieleiey, 600'G. 9.6 aut tre ecb 6 95 
UAE Lae Ske ayy he RGA dee nie aete oes os SAPP Gd ccevotes 27 
Se CLO RSE aera i yo cre ea te a nbs 8 ERD Ls eae Od clare 164 
Do TIE Ae Gael ee a a oe Wee eet 
COL et iaiil vs fini ees Beales ie AEA eed 25, 53 
ee IMIEL LD OLIC 2 ose <a a4 vis gai RM oc Sies Wb Wiles 8's4e lw nies e's’ 251 
EMME AL EVOL (Waal a's, aX 65's 2.c'e 4 4 y's cle de eins os 8 See ciiae « 220 
PEERS as Bae yikes 6 bg skis k's fed £4 5 Ok cee te Ge eee ee eee 76 
Pica rodah StLUSiON;, GIALNOSIS OF 5 oc...» vers soi ste sials Sele less 241 
Phenomenon,.cardio-splanchnic, ..,....60500 006 secwanes 116, 200 
RE a yo d eve ruses casy ois 6. nce ATs; obo 0,0 Foca ein's: vole bea le sia Sle aber 58 
De NEAPRRE AEE la, GTS cr rays nn, siston eye, afaye(4/eirps noes i Ore emia ae al 175 
CaM Oy Chic eo cly's Js 0 So 6 Gs sera ps ¥ 0 wie'e ® o'ys ip ero sew asia 187 
Peete SESS FRI. Sao Fd S45 asl ds oth tid ong wPidet omy on os 119, 215 
BURR BEnEs CUA E LAL cccaityaterera dock ate eek cies aekisye wah hae ee 112, 118 
RIMS AMR LNA Doce oie pele eke, cis eyes ow ie em wee es ss 63, 187, 196 
EGRET MN aia ats, ecicisia'a x a aia sel qcee ts ait BALD S HeLa whine ee MM os 115 
MIRO CARAT rs, no's one Sid's 5-8 Fas pis 9i8 ate Wl vine BS ecrieras ew 62 


Purgatives, PP ONE IATL a peeiiy caniceiy ina otis «Sree ce ek ee ee 158 


286 INDEX. 


PAGE 

Railway spine. .'ces ees ccc'c ens awelde'acsw dees seule sagt aman 
Reflex, heart........ elsteletslele stare sintate 6:0 sitar cae sates ean 237 
Liver chit sss 5 snes seb wees swiur erie s sas coms sear 129, 231 
lung’ of contraction: /.vi.<.c.-.5ssersaewans 247 
lung of dilatation........ swae sve sicles bb am eee Pt 244 
Respiratory @Xercises.......secessee os tc 0 6 eemecicsn oe eee 148 
Rest cure tl. ccc cies cd ha ci b tse cscae tabs « sme Ree . 83 
Rest'cure; partials 3.6 ci esd cbc cen uns ccecces aunt an 86 
Restlessness......s..00. Se ships w ane wis tiotiay 000s a diesen geen 60 
ReOVOEPrSlOns Ps Fs SSIES Ne oe Rae ces ees dlp o oe ses ee cutee een 252 
Riva-TOCCl oie as viwiee's ecaee nite eis sci PE es Ae ovos.ee Rereee 215 
Rumpf’s symptoms. ...tsseeness es WETrerererririe rye rt 
Self-Control. 73 vases oh bee ewan eee a ate sheesh bhirtgier Vs sen Cop 
Seminal emissions, treatment OL.) . 34555 +. cca sess oe eee 102 
Sensory disturbances (5 s2c. cis ce esccas eee seed sean tne eens 55 
Sexual hypochondriac........... sootanaeed eo. chu: 69 
NEUrAasthenigs, Liew ccces sev ucecles soe cddes Teen 101 
SIsin Poise es eras ese tees Seoedecnsetdseauas cue che ten 67 
SIRMSOIGAL CULTEOL cs cccesecenccee: saudde ov ae k here 151, 256, 266 
Sleep..... Shiai aie as ~ ate Swit pe on a viaccess rrr err S 88 
Sleeplessness........ pate 6 estes ieee sin 's Sie «sable are 69, 89 
Spermatorrhesair ye ve dees es < oo a0 ae R ee wee Pr te 68 
Spinal irrilgtion. Sivas ves <cese se scenes css sas bs emp ee 72 
Splanchnic neurasthenia, the vasomotor test in............. 275 
Splanchnic neurasthenia, case Of... Ss...0.~+ + «se eee eee 123 
CASCH OL dee cee ae U viatis do't'nib's tec ditre cece eiphe enter ema 153, 157 
CAUSES OFS 2.5 Wis i sows ole te'alalaue's's clein'ele\s sie tem eleinee Pe iy Pe 117 
recapitulation of...... Peco Wels tse eee ae in ek sine 121 
SYMPtOMS*OF. F505 oss ss aces ces locks aces oe ews plates 123 
treatment of ........ ane ss dan eds ve ee we te 55s cco oan 137 
Stethophonometer.: «2% 25. sss rsee caeles ssc 0 0 o'elanis ae 215 
elLigmata ss sissee cea ob eb 55% die ee cleat 00 4's 5/0 bree e 5 ean 1% 
Stomach, action on heart, 218; stomach percussion......... 269 
Suction, PulMONAry . ssi oc/0+%0 oe sy os asesewies o¥ e 0:0 le eee te 115 
Sulphates..... SrA pT ECC at sah. v we we duacietce oem je soo eee ual 
Supporters, abdominals. ssiec cine siseeeeue onus oul eaten Ae kay 
Sympathetic, abdominal........... .. ree er rr AB aL: 


INDEX. 987 


: PAGE 

OF PUI. 56s Meet pire ssipt iad e eee saw asie se tas lve swe sees sth OL 
SL Osiiier arg 2s’. 5's re alee Manne cov a Sb San ttediee. sete aes ides 30 
Perio iilitn-BOOOMIN Al co... vccc ees beeceacsecee 112, 118, 267 
PETA MCUILOUGS « scaec os cu irse Cued es tdeeesse cs cacvee 212 
OMOMLOUCL. oc sc cessises PN eis e cu tins ae «+ 6 o> Leese PALE 
Test of Obermayer........... Sette Cine macs oes se Pivetes cathe 
TEGUIOE re ie oss «0'o eos s Pty Sol AIO RES EET Ee PERE LE 55 
MCTCP MCT ears s Gee 46 a s'e0 Samet at aac ee 2 CNT ecer S ad ot ae cane Steet 
diathesis..... Meiers See inet ON cs ars vee ier ri avec 40 
ASSAD AUROUIO Sos vs ck as 5's Leese s eet aen Poa ree 131 

Ure NT ee ae SP i CL EOE CEN ELLER RIO ae detest 170 
ON ee es gts Pidtateiecie areola: a RRA EEO. © <a ee ROU 
RPEM ERIN sc cle alee Cw ee Cee aw ies Sete ts Pitcis oo dee + akieke 61 
eto eS DIATCUNIG. cis seve sce oars sate ese Suess Slee c Beierests 114 
WIEN LACIVING Le Veeaks ate bate o eiite oictele ele as vo View alae Kealass 125 
Maer COLO Gov. sev bv ns o ves te eRe cx oa: s # viv wie ect nce bie 0 153 
iW eakness, HEArt ...0csiescsavcnss Fete Cones eerie cere 131 
WWREREMIGTI GS TOLIGL LOL.. ccee ciorccocss sev atieece Crees ee 83 
SMAECRE IST olslateve ius viaje «4 sce :0 3 pais ae oka s acre ces Ces Brie wae et RL 


Zones, PEP IBCLULIGMER Tera Lote ude cvs teee neces eosepesevess 191 





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